HISTORY OF PRESENT ILLNESS: 78-year-old male with a ...



HISTORY OF PRESENT ILLNESS: 78-year-old male with a history of carcinoma of the bladder diagnosed in March of 1999, who present for preoperative evaluation. The patient has undergone periodic cystoscopies and on the recent cystoscopy a lesion was found. This has since been shown to be a recurrent bladder carcinoma and the patient is now scheduled for cystoscopic removal.

MEDICATIONS: None

ALLERGIES: NONE.

PAST MEDICAL HISTORY:

1. Carcinoma of the bladder as noted above.

2. A status post right cataract extraction in 03/95.

3. History of pilonidal cyst, 40 years ago.

FAMILY HISTORY: Mother died at age 93 of natural cause. Father died at age 79 of a stroke. The patient has no siblings.

SOCIAL HISTORY: The patient is a widower with two children. He is a bandleader. He does not smoke and drinks very rare alcohol.

REVIEW OF SYSTEMS:

HEENT: Unremarkable.

RESPIRATORY: No cough, shortness of breath, or wheezing.

CARDIOVASCULAR: No chest pain, palpitations, dyspnea on exertion. The patient does not exercise regularly but he is very active.

GI: He denies any constipation, diarrhea, nausea, vomiting, or abdominal pain. He denies reflux symptoms. He had a flexible sidmoidoscopy in April of 1995.

GU: Remarkable for history of a bladder cancer and nocturia one time per night.

NEUROLOGIC: Unremarkable.

MUSCULOSKELETAL: Unremarkable.

PYSICAL EXAMINATION:

VITAL SIGNS: Blood pressure is 142/72. Pulse is 80. Temperature is 97.5 F.

HEENT: Unremarkable.

NECK: Neck is supple without JVD, adenopathy, thyromegaly, or bruit.

LUNGS: Lungs are clear.

CARDIAC: Regular rate without murmur.

ABDOMEN: Soft, nontender without a hepatosplenomegaly. No abdominal bruits are noted.

GU: Exam was deferred.

MUSCULOSKELETAL: Unremarkable.

EXTREMITIES: Distal pulses are 2+. There is no edema.

NEUROLOGIC: Nonfocal.

ASSESSMENT AND PLAN:

1. Recurrent bladder carcinoma. The patient’s chest x-ray, EKG, and labs have been reviewed and he is cleared for surgery.

2. Hypercholesterolemia. This was discussed at length with the patient, as his C-reactive protein and homocysteine are normal, the patient will attempt six months of diet and exercise. A diet sheet has been given for the patient to review. This will be checked in six months.

3. General. The labs were reviewed with the patient. He has also been instructed to set up a colonoscopy. The patient will return for a full follow-up in one year.

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