[doctor] i know the nurse told you about dax .
[patient] mm-hmm
[doctor] i'd like to tell dax a little bit about you , okay ?
[patient] sure .
[doctor] so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ?
[patient] um , relatively speaking , okay . it was kind of a , a tough spring with all the pollen and everything and , uh , we dropped my oldest daughter off at college and moved her into her dorm , so little stressful , little chaotic , in the heat of the summer , but so far , so good .
[doctor] okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing .
[patient] yeah .
[doctor] so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year .
[patient] yeah , i've been staying on top of the meds , and i have n't had any incidents in a while , so it's , it's been pretty good , and everything's managed and maintained . um , still kind of working with my hypertension . that's been a little bit more of a struggle than anything .
[doctor] okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ...
[patient] i ... i'm pretty regular with the medications during the business week , but on there's weekends , you know , if i'm on the fly or doing something , sometimes i forget , or i forget to bring it with me . uh , but for the most part , it's been okay .
[doctor] okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ?
[patient] other than during the heat and the pollen , it's been pretty good .
[doctor] okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ?
[patient] sometimes i , i regularly , uh , go for a run in the morning . that's my workout , and sometimes if it's , uh , relatively humid , i'll struggle a little bit , and i might feel a little bit of pounding in my chest . it usually goes away , but , uh , again , for the most part , it's been pretty good .
[doctor] okay , so you also have some shortness of breath with with exertion .
[patient] correct . correct .
[doctor] all right , and how far are you running ?
[patient] uh , like 4 to 5 miles a day .
[doctor] okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure .
[patient] mm-hmm .
[doctor] hey , Sarah , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , Sarah , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it has in the past , so continue on the current medication .
[patient] mm-hmm .
[doctor] all right , so i'm just gon na listen to your heart and lungs and check you out , okay ?
[patient] you got it .
[doctor] okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , Sarah , show me the ekg . so they did an ekg before you came in today .
[patient] mm-hmm .
[doctor] and in reviewing the results , it looks like your ekg is completely normal , so that's good .
[patient] good .
[doctor] so i'm not too concerned about that , that chest pounding . hey , Sarah , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my assessment and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well-
[patient] mm-hmm .
[doctor] . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ?
[patient] uh , actually , i do need a refill .
[doctor] okay . hey , Sarah , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow up with the surgeon anymore . and then for your last problem , your hypertension .
[patient] mm-hmm .
[doctor] you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , Sarah , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ?
[patient] perfect .
[doctor] all right . good to see you .
[patient] same here .
[doctor] hey , Sarah , finalize the note . the nurse will be in .
[patient] thank you .
CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

The patient is a 62-year-old male with a past medical history significant for depression and prior lobectomy, as well as hypertension. He presents for his annual exam.

The patient reports that he is doing relatively well. Over the summer, he moved his oldest daughter into college which was a little stressful and chaotic in the heat of the summer.

Regarding his depression, he reports that he has been consistent with his Prozac and has not had any incidents in a while.

His hypertension has been slightly uncontrolled. He reports that he is taking his blood pressure at home and it is running high. The patient states that he is pretty regular with his Norvasc during the business week, but on the weekends he will forget to bring it with him.

He reports that he had a prior lobectomy a couple of years ago. He endorses shortness of breath with exertion. The patient has difficulty breathing due to allergies and the heat in the summertime. He also endorses some nasal congestion from the pollen. He reports that he runs in the morning. Occasionally, if it is relatively humid, he will struggle a little bit with breathing and he will feel a little bit of a pounding in his chest. He states that it usually goes away. He reports that he runs 4 to 5 miles a day.

REVIEW OF SYSTEMS

• Ears, Nose, Mouth and Throat: Endorses nasal congestion from the pollen.
• Cardiovascular: Endorses intermittent palpitations. Endorses dyspnea on exertion.
• Respiratory: Endorses shortness of breath. Endorses cough.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Head and Face: Pain to palpation to the sinuses.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate. 2/6 systolic ejection murmur. No gallops or rubs. No extra heart sounds.

VITALS REVIEWED
• Blood Pressure: 124/80 mmHg.

RESULTS

Electrocardiogram stable.

X-ray of the chest is unremarkable.

ASSESSMENT AND PLAN

Ralph Barnes is a 62-year-old male who presents for his annual examination.

Annual visit.
• Additional Testing: I have ordered his routine blood work and will follow up with the patient via the portal once results are back.

Depression.
• Medical Reasoning: He is doing well with his current regimen.
• Medical Treatment: He can continue Prozac 20 mg a day and I provided a refill of that today.

History of lobectomy.
• Medical Reasoning: I do not think we need to do any more work up for this issue. He is able to exercise a lot and his breathing function is back. I do not think he needs to follow up with the surgeon anymore.

Hypertension.
• Medical Reasoning: He is doing well on his current regimen. His blood pressure was normal today and has been trending well over the past several years.
• Additional Testing: I ordered an echocardiogram to evaluate his murmur.
• Medical Treatment: He can continue Norvasc.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
