ASSESSMENT:

The patient's condition is
 new.

PLAN:

1. Patient is doing well. Preventive care updated.
2. Patient Counseling:
--Nutrition: Stressed importance of moderation in sodium/caffeine intake, saturated fat and cholesterol, caloric balance, sufficient intake of fresh fruits, vegetables, fiber, calcium, iron, and 1 mg of folate supplement
per day (for females capable of pregnancy).
--Discussed the issue of estrogen replacement, calcium supplement, and the daily use of baby aspirin.
--Exercise: Stressed the importance of regular exercise.
--Substance Abuse: Discussed cessation/primary prevention of tobacco, alcohol, or other drug use; driving or other dangerous activities under the influence; availability of treatment for abuse.
--Sexuality: Discussed sexually transmitted diseases, partner selection, use of condoms, avoidance of unintended pregnancy  and contraceptive alternatives.
--Injury prevention: Discussed safety belts, safety helmets, smoke detector, smoking near bedding or upholstery.
--Dental health: Discussed importance of regular tooth brushing, flossing, and dental visits.
--Immunizations reviewed.
--Discussed benefits of screening colonoscopy.
--After hours service discussed with patient

3. Discussed the patient's BMI with him.  The BMI is above average; BMI management plan is completed
4. Follow up in one year

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