Male Annual Wellness Visit Note

Chief Complaint

• Annual wellness visit
• Chronic hypertension follow-up
• Hyperlipidemia follow-up
• Right shoulder pain

HPI

1. Preventive Care: 58 y/o M presents for annual wellness examination. Feels generally well without acute systemic complaints.
2. Essential Hypertension: Diagnosed 5 years ago. Adherent to lisinopril 20 mg PO daily. Home BP logs average 126/78 mmHg. Denies headache, chest pain, or visual changes. Previously managed with lifestyle modifications alone, which was ineffective; current regimen provides good control.
3. Hyperlipidemia: Diagnosed 3 years ago. Adherent to atorvastatin 20 mg PO daily. Denies myalgias or weakness. Fasting lipid panel last week showed improved LDL compared to prior year.
4. Right Shoulder Pain: Gradual onset 3 weeks ago after overhead yard work. Located at the anterolateral right shoulder. Characterized as a dull ache (3/10 at rest), worsening to sharp pain (6/10) with overhead abduction and internal rotation, and disturbing sleep when lying on the right side. Relieved partially by rest and paracetamol (acetaminophen, Tylenol®) 500 mg PO PRN. Had a similar episode 2 years ago that resolved completely with 4 weeks of conservative home exercises and NSAIDs.

Male AWV

• Nutrition: Follows a Mediterranean-style diet, limits processed meats and refined sugars.
• Exercise: Brisk walking 30 minutes 4 times weekly; light resistance training twice weekly.
• Falls: Denies any falls in the past year.
• EtOH/Tobacco: 2–3 beers per week; former smoker (quit 15 years ago, 10 pack-year history).
• HTN screen: Today's BP is 128/80 mmHg.
• Cholesterol: LDL 88 mg/dL (12/05/2026), down from 112 mg/dL (10/05/2025).
• 10 year CV risk %: 7.2 % calculated via pooled cohort equations.
• STD screen: Declined today; mutually monogamous relationship. No recent screening.
• One time HIV/HBV/HCV screen: HIV negative, HCV antibody non-reactive, HBV surface antigen negative (14/04/2022).
• Depression (PHQ2/9): PHQ-2 score 0. Denies depressed mood or anhedonia.
• Anxiety (GAD2/7): GAD-2 score 0. Denies nervousness or uncontrollable worry.
• Med review: medication list reviewed and confirmed
• PSA discussion: Shared decision-making completed regarding risks and benefits of prostate cancer screening; patient elects to proceed with PSA testing today.
• DEXA if at high risk: n/a
• Colon CA screen: Screening colonoscopy on 18/06/2021 was normal; next due 06/2031.
• AAA screen: Discussed one-time screening abdominal ultrasound; not yet indicated as patient is under 65.
• Lung CA Screen: Does not meet criteria (10 pack-year history, quit 15 years ago).
• Advance Care Planning: Has a durable power of attorney for healthcare (spouse) and living will on file; no changes requested.

Medical Diagnoses

1. Essential hypertension
2. Hyperlipidemia
3. Cerumen impaction, left ear

Specialist Care

1. Dr. Sarah Jenkins, Gastroenterology (screening colonoscopy)

Medications

1. lisinopril (Prinivil®) 20 mg PO daily
2. atorvastatin (Lipitor®) 20 mg PO QHS
3. paracetamol (acetaminophen, Tylenol®) 500 mg PO Q6H PRN pain

Supplements

1. colecalciferol (Vitamin D3) 1,000 IU PO daily
2. omega-3-acid ethyl esters (Fish Oil) 1,000 mg PO daily

Review of Systems

• Constitutional: No fever, chills, fatigue, or weight changes.
• Eyes: No vision changes, redness, pain, or discharge.
• Ears, Nose, Throat: Reports mild muffled hearing in the left ear for 1 week. No tinnitus, nasal congestion, rhinorrhea, sore throat, or dysphagia.
• Cardiovascular: No chest pain, palpitations, or edema.
• Respiratory: No shortness of breath, cough, or wheezing.
• Gastrointestinal: No nausea, vomiting, diarrhea, constipation, or abdominal pain.
• Genitourinary: No dysuria, hematuria, urinary frequency, or urgency.
• Musculoskeletal: Reports right anterolateral shoulder pain with overhead movement. No joint swelling or systemic stiffness.
• Skin: No rashes, lesions, or itching.
• Neurologic: No headaches, dizziness, numbness, or weakness.
• Psychiatric: No anxiety, depression, or mood changes.
• Endocrine: No polyuria, polydipsia, or heat/cold intolerance.
• Hematologic/Lymphatic: No easy bruising, bleeding, or lymphadenopathy.
• Allergic/Immunologic: No allergies, sneezing, or hives.

Physical Exam

• Constitutional: Well-developed, well-nourished male in no acute distress.
• Vital Signs: BP 128/80 mmHg, HR 72 bpm, RR 14 breaths/min, Temp 36.8 °C, SpO2 99 % on room air, Weight 84.5 kg, Height 178 cm, BMI 26.7 kg/m².
• Head: Normocephalic, atraumatic.
• Eyes: Conjunctivae clear, sclerae anicteric, PERRLA, EOMI.
• Ears, Nose, Throat: Right tympanic membrane pearly grey with normal landmarks. Left external auditory canal 100 % occluded by dark brown cerumen; tympanic membrane visualized as normal following cerumen removal. Oropharynx clear, mucous membranes moist.
• Neck: Supple, no thyromegaly, no lymphadenopathy, no carotid bruits.
• Cardiovascular: Regular rate and rhythm, normal S1 and S2, no murmurs, rubs, or gallops. Peripheral pulses 2+ bilaterally.
• Respiratory: Lungs clear to auscultation bilaterally, no wheezes, rales, or rhonchi. Normal respiratory effort.
• Gastrointestinal: Abdomen soft, non-tender, non-distended, normoactive bowel sounds, no hepatosplenomegaly.
• Genitourinary: External genitalia normal, no hernia palpated, testes descended bilaterally without masses.
• Musculoskeletal: Normal gait and station.
  • Right glenohumeral joint: No erythema, ecchymosis, or muscular atrophy. Mild tenderness to palpation over the subacromial space and supraspinatus tendon insertion. Full passive ROM; active abduction painful between 70 and 120 degrees (positive painful arc test). Positive Neer impingement sign and positive Hawkins-Kennedy test. 5/5 strength with external rotation and abduction; negative drop arm test.
• Skin: Warm, dry, intact, no suspicious nevi or rashes noted on total body skin exam.
• Neurologic: Alert and oriented x3, cranial nerves II–XII intact, sensation intact to light touch in bilateral upper extremities, DTRs 2+ and symmetric.
• Psychiatric: Cooperative, appropriate mood and affect, normal judgment and insight.

Labs / Imaging / Diagnostic Tests

1. Comprehensive Metabolic Panel (12/05/2026): Fasting glucose 94 mg/dL, BUN 16 mg/dL, Creatinine 0.9 mg/dL, eGFR > 60 mL/min/1.73m², Na 140 mmol/L, K 4.3 mmol/L, AST 22 U/L, ALT 25 U/L. Stable trend; next due in 12 months.
2. Lipid Panel (12/05/2026): Total Cholesterol 165 mg/dL, Triglycerides 110 mg/dL, HDL 55 mg/dL, LDL 88 mg/dL (improved from 112 mg/dL on 10/05/2025). Next due in 12 months.
3. Hemoglobin A1c (12/05/2026): 5.4 % (stable from 5.5 % on 10/05/2025). Next due in 12 months.
4. Complete Blood Count (12/05/2026): WBC 6.2 x10³/µL, Hgb 15.1 g/dL, Hct 45.0 %, Platelets 240 x10³/µL. Normal.
5. Colonoscopy (18/06/2021): Normal mucosa to cecum, no polyps. Next due 06/2031.

Assessment & Plan

1. Preventive Care (Z00.00)

Assessment: 58-year-old male here for his routine annual wellness examination. He remains physically active, maintains a balanced diet, and is up to date on colorectal cancer and infectious disease screenings. Shared decision-making was completed today regarding prostate cancer screening.

Plan:

• Order total serum PSA lab test today.
• Continue colecalciferol (Vitamin D3) 1,000 IU PO daily and omega-3-acid ethyl esters (Fish Oil) 1,000 mg PO daily.
• Encourage continued adherence to Mediterranean diet and regular aerobic/resistance exercise.
• Return to clinic in 1 year for next annual wellness visit.

2. Essential Hypertension (I10)

Assessment: Blood pressure is well-controlled on current monotherapy, as evidenced by today's clinic reading of 128/80 mmHg and consistent home readings averaging 126/78 mmHg. Renal function and electrolytes remain stable on recent laboratory evaluation.

Plan:

• Continue lisinopril (Prinivil®) 20 mg PO daily.
• Continue home blood pressure monitoring weekly.
• Repeat CMP in 12 months prior to next annual visit.

3. Hyperlipidemia (E78.5)

Assessment: Dyslipidemia is well-managed with current statin therapy, showing a favorable downward trend in LDL from 112 mg/dL last year to 88 mg/dL this week. 10-year ASCVD risk is calculated at 7.2 %, and the patient is tolerating therapy without hepatotoxicity or myopathy.

Plan:

• Continue atorvastatin (Lipitor®) 20 mg PO QHS.
• Repeat fasting lipid panel in 12 months.

4. Right Shoulder Pain (M25.511)

Assessment: Patient presents with subacute right anterolateral shoulder pain following overhead physical exertion. Given the absence of imaging, the differential diagnosis ranked from most to least likely includes subacromial impingement syndrome / rotator cuff tendinopathy, partial-thickness supraspinatus tear, and acromioclavicular joint osteoarthritis. Physical examination strongly supports rotator cuff tendinopathy with impingement, and intact strength makes a full-thickness tear unlikely. Symptoms are similar to a prior episode two years ago that resolved with conservative management.

Plan:

• Discontinue paracetamol and initiate naproxen (Naprosyn®) 500 mg PO BID with food for 10 days for anti-inflammatory control.
• Provide handout for home rotator cuff strengthening and scapular stabilization exercises; advise avoidance of heavy overhead lifting for 2–4 weeks.
• If no significant improvement in 4 weeks, return to clinic to consider right shoulder X-ray and formal physical therapy referral.

5. Impacted Cerumen, Left Ear (H61.22)

Assessment: Patient reported mild left-sided conductive hearing muffling, found on otoscopy to be secondary to complete cerumen impaction of the left external auditory canal. This was successfully resolved via mechanical irrigation in the clinic today.

Plan:

• Lavage performed today with complete resolution of impaction and symptoms.
• Advise against use of cotton-tipped applicators in the ear canal.

Procedure Note

• Patient Name: Robert Miller
• Date of Procedure: 19/05/2026
• Procedure Performed: Left ear cerumen removal via irrigation
• Indication: Symptomatic complete cerumen impaction of the left external auditory canal causing muffled hearing
• Pre-Procedure Diagnosis: Impacted cerumen, left ear (H61.22)
• Post-Procedure Diagnosis: Impacted cerumen, left ear (H61.22)

Details of Procedure

• Consent: Informed consent was obtained after discussing risks, benefits, and alternatives.
• Preparation: The patient was positioned seated upright with a collection basin held beneath the left ear. Otoscopic examination confirmed complete occlusion without history of tympanic membrane perforation. Cerumenolytic drops were instilled 15 minutes prior to irrigation.
• Procedure Steps: Using a 60 mL syringe with an angiocatheter tip, the left external auditory canal was gently irrigated with body-temperature sterile water and hydrogen peroxide solution directed at the superior-posterior canal wall. After three flushes, a large cerumen plug was evacuated into the basin.
• Findings: Post-procedure otoscopy revealed a completely clear left external auditory canal and an intact, pearly grey tympanic membrane with normal landmarks and mild, expected canal erythema.
• Complications: None.

Post-Procedure Care

Patient tolerated the procedure well.

• Post-procedure monitoring: Patient reported immediate improvement in hearing and denied vertigo, pain, or bleeding prior to discharge.
• Follow-up plan: Call clinic if ear pain, purulent discharge, or dizziness develops; otherwise routine follow-up PRN.

Medications Administered

carbamide peroxide 6.5 % otic solution (Debrox®), 5 drops instilled into left external auditory canal x 1 dose prior to irrigation.