Outpatient Office Visit
Patient Case Number: OPOV43-Polansky, Wendell
Patient Name: Wendell Polansky | DOB: 02-11-71 | Sex: M
Date of Service: 06-11-XX | Physician: Juan Martinez, MD

Chief Complaint: Lung mass

History of Present Illness:

The patient is an established patient and presents today with some back problems. He had a chest xray and a CT scan which showed azygos lobe which is a congenital anomaly without any consequence, but at the same time he was found to have multiple small nodules in the lung which were followed by Dr. Milly. For a while it had shown some slight increase, not so much in the nodules, but in the pretracheal area. The paratracheal lymph nodes on the PET scan showed significantly increased activity within these lymph nodes. The lung nodules had remained about the same size and had not increased in size. A couple of the lung nodules were calcified. The patient himself remains asymptomatic and has not had any cough with expectoration or hemoptysis and no weight loss.

# PFSH: As documented. I have reviewed and agree with prior documentation.

# Review of Systems

General/Constitutional: denies recent weight loss, denies recent weight gain, denies fever, denies chills, denies change in exercise tolerance

Integumentary: denies change in hair or nails, denies rashes, denies skin lesions Eyes: denies diplopia, denies visual field defects, denies blurred vision, denies eye pain, denies discharge

Ears, Nose, Mouth, Throat: denies hearing loss, denies epistaxis, denies hoarseness, den ies difficulty speaking

# Respiratory: snoring

Cardiovascular: denies palpitations, denies chest pain, denies peripheral edema, denies syncope, denies claudication

Gastrointestinal: denies ulcer disease, denies hematochezia and denies melena

Genitourinary Male: non-contributory

Musculoskeletal: reports back pain, arthritis

# Neurological: denies strokes, denies TIA, denies seizure disorder

# Psychiatric: reports depression

# Endocrine: denies heat/cold intolerance, denies polydipsia, denies polyuria Hematological/Immunologic: denies food allergies, denies seasonal allergies, denies bleeding disorders

# Sleep History: CPAP/BIPAP/VPAP/O2 recheck

# Medical History: Bipolar d/o, OSA, hyperlipidemia

# Medications:

1. Atenolol 25 mg Tablet 1 by mouth daily

2. Crestor 10 mg tablet 1 by mouth daily

3. Fenofibrate 160 mg tablet 1 by mouth daily

4. Fish Oil 1,000 mg Capsule 1 by mouth daily

5. Norco 5 mg-325 mg tablet as needed

6. Seroquel 200 mg Tablet 1 by mouth daily

7. Vitamin B Complex Tablet l by mouth daily

8. Aspirin Low Dose 81 mg tablet, delayed release 1 by mouth daily

9. Seroquel 200 mg Tablet 1 by mouth daily

# Surgical History: Arthroscopic knee sx, appendectomy

# Vital Signs: BP-118/78, Pulse-60, Weight-250lbs, Height-5’9”, O2 Sat-98%, BMI-36.9

# Physical Examination

Constitutional: cooperative, alert and oriented, well developed, well nourished, in no acute distress

# Skin: warm and dry to touch, no apparent skin lesions, no apparent masses noted

# Head: normocephalic, non-tender, no palpable masses

Eyes: EOMS Intact, PERRL, conjunctivae and lids unremarkable

ENT: ears unremarkable, throat clear, without erythema, good dentition

# Neck: no palpable masses or adenopathy, no thyromegaly, JVP normal, carotid pulses are full and equal bilaterally without bruits

# Chest: normal symmetry, no tenderness to palpation, normal respiratory excursion, no intercostal retraction, no use of accessory muscles, normal diaphragmatic excursion, clear to auscultation

Cardiac: regular rhythm, Sl normal, S2 normal, no S3 or S4, apical impulse not displaced, no murmurs, no gallops, no rubs detected

Abdomen: abdomen soft, bowel sounds normoactive, no masses, non-tender, no bruits

Peripheral Pulses: femoral pulses are full and equal bilaterally with no bruits auscultated, popliteal pulses are full and equal bilaterally with no bruits auscultated, dorsalis pedis pulses are full and equal bilaterally with no bruits auscultated, posterior tibial pulses are full and equal bilaterally with no bruits auscultated

Lymphatic: no lymphadenopathy

Extremities & Back: no deformities, no clubbing, no cyanosis, no erythema, no edema, there are no spinal abnormalities noted, normal muscle strength and tone Psychiatric: appropriate mood, memory and judgment

Neurological: no gross motor or sensory deficits noted

Impression/Plan:

1. Enlarged lymph nodes (localized): I have discussed the findings with the patient and his wife and told them that we should consider a mediastinoscopy given the significantly increased activity within these lymph nodes to get a diagnosis. I discussed with them the risks of surgery, including risk of infection, and bleeding. The patient is agreeable and we shall schedule for surgery as soon as possible.

2. Bipolar d/o-continue Seroquel

3. Hyperlipidemia-continue fish oil and Fenofibrate

4. OSA-CPAP

# Electronically Signed By: Juan Martinez, MD

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