[doctor] eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions .
[doctor] of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the patient's alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 .
[doctor] good morning , mr. walker . how are you doing ? i mean , it's been a crazy year .
[patient] i'm doing fine , for the most part , but there are a few things i want to cover today .
[doctor] sure . go right ahead .
[patient] uh , well , i'm having more fatigue , but i do n't know if it's age or if it's just , you know , drained at the end of the day . but i still ride my bike . i ca n't go as fast as i used to . i'm still riding , and , you know , after a long bike ride , i'll sit down and then boom . i'm out , you know ?
[doctor] yeah . what's a long bike ride to you ?
[patient] uh , 20 to 30 miles .
[doctor] 20 to 30 miles on a road bike ?
[patient] yeah , road bike . i think it's a time thing . if i had more time , i would try to do my 40 miles , but i have n't done that . obviously , we're too early in the season so my typical ride is , like , 20 , 30 . in years back , i could do 40 on a good day . i can still do 20 but , you know , i'm tired and have to take a break when i get home .
[doctor] yeah , i understand .
[patient] and tyler's my buddy . he's always nice and waits for me , but i used to be able to beat him . but now , he waits for me all the time . he's older than me and it- it kills me .
[doctor] yeah , i can imagine that would upset me too .
[patient] well , the last time , you know , you found a heart thing , then . just making sure that the valve is holding out , you know ?
[doctor] right . so , when was your last stress test ?
[patient] it was september 9th , 2019 , because i'm eight years out from surgery , and back then , they said , you know , it's going to last eight years . and i'm at that year , so i just want to make sure . i asked dr. lewis for an echocardiogram to see how i'm doing .
[doctor] yeah .
[patient] but it's not ... like , nothing has changed drastically since i saw you .
[doctor] okay , good . do you still go down to hopkins at all ?
[patient] no , not at all . i just get follow-ups intermittently , here . going there is just ... it's too much stress .
[doctor] okay .
[patient] one more thing , i want to make sure i do n't forget . my wife and friends tell me that when i walk , i purse my lips when i'm breathing . other doctors have said , " did you notice your pursed lips breathing ? " i do n't know if that's a bad habit or what .
[doctor] okay . is there any wheezing associated with that ?
[patient] no , no wheezing .
[doctor] and you're able to bike 30 miles and mostly keep up with your friend , tyler , correct ?
[patient] yeah . the only other thing i want to mention is it's not like i do routine testicular exams , but i know i have this little nodule on my right testicle .
[doctor] on the testicle or the epididymis ?
[patient] epididymis . uh , i really do n't know . i'm not super concerned . i read a little online . just wanted to ask you .
[doctor] and did you have a vasectomy ?
[patient] no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those were the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know ? i just know you would ask those questions .
[doctor] what time are you going to sleep , and about how many hours do you sleep a night ?
[patient] um , it varies . usually , i get six to seven hours of sleep . i get out of bed some days to be at work by 7:00 , lecture , and i try to work out in the morning . i- i do n't ... i'm not ... i'm not always successful , and now what i do is i- i do make reservations twice a week for a 5:45 swim in the morning .
[doctor] okay , so you're getting six to seven hours of sleep , and has your wife ever mentioned if you snore or stop breathing at any time ?
[patient] i believe i snore a little bit , but she's never said anything about me not breathing .
[doctor] okay . so , you're currently taking vitamin d3 , around 5000 units on sundays , and two thous ... or 50,000 units on sundays , excuse me , and 2000s on the other six days , and then clindamycin prior to dental procedures , correct ?
[patient] yeah , that's right .
[doctor] have you had a covid-19 shot yet ?
[patient] i've received both . my first dose on january 15th , '21 and my second on february 5th , '21 .
[doctor] good . if you'd hop up here on the table , we're just going to do a physical exam .
[doctor] well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you .
[patient] all right .
[doctor] also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today .
[patient] you're going to have them done today ?
[doctor] yes , sir , and we will send the results through your patient portal unless something is way off then we'll give you a call .
[patient] sounds good .
[doctor] now as far as your breathing , i observed the pursed lip breathing and your exhalation is low . i think you should do a pulmonary function test to further evaluate , and i'll order that as well .
[doctor] now the nodule in your right testicle should be evaluated by urology , and we will place that referral today , also .
[patient] sounds like i'm going to be busy getting this all checked out .
[doctor] yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good .
[doctor] now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies .
[doctor] do you have any other questions for me ?
[patient] no , doc . i think you covered it all .
[doctor] great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month .
[patient] thanks , doc . have a great day .
[doctor] all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default .
[doctor] assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test .
[doctor] elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt .
[doctor] lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation .
[doctor] the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound .
[doctor] preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 .
[doctor] patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .

Medical orders:
description: blood mmr titer today
order_type: lab
description: follow-up in one year sooner if needed
order_type: followup
reason: for a wellness visit
description: echocardiogram
order_type: imaging
description: alkaline phosphatase blood
order_type: lab
description: gt blood
order_type: lab