Patient Name: Sxxxxx Pxxxx Age: 35
Sex: MaleDOB: xx/xx/1978
CC: Mr. “SP” presents complaining of “frequent urination” and “feeling thirsty all the time”.
HPI: Patient is a 35-year-old male with history of hypertension and hyperlipidemia. Patient recalls that symptoms became worst about a week ago. He noticed that he needed to take more breaks at work to use the restroom, from three to four times in his eight-hour shift to almost every hour frequency. Denies burning, hesitance, or pain with urination. He also recalls his fluid, mainly water, intake has increased because he feels thirsty often; three to four glasses more a day. He tried to drink less fluid to avoid urinating so frequently, but became thirty soon and couldn’t refrain from drinking fluids. He started to get worried about the symptoms and called the office to make an appointment for today. No previous episode of similar symptoms. Patient’s hyperlipidemia is currently being treated with simvastatin and his hypertension with enalapril. He states he has been taking all his medications.
PMH: Hypertension controlled with enalapril and Hyperlipidemia controlled with simvastatin.
PSH: Denies
Medications: Enalapril 10mg PO daily. Simvastatin 20mg PO daily
Allergies: No known drug or food allergies
FMH: Father is living, age 65 – CAD, MI x2 (first one before age 40), Hypertension, Hyperlipidemia,
Diabetes Mellitus Type II, Bronchiectasis. Mother is living, age 57 – Hypertension. Patient has 4 brothers, all are living. Older sibling, age 41, with history of Hyperlipidemia and MI at age 30. Other siblings in good health.
SH: The patient is single and has no children. Live in a single-family home with family members. He is a telecommunication engineer and works as one for a friend’s company. He is insured through his work of employment. He is fluent in English and Spanish, but