[doctor] morning christine , nice to see you .
[patient] nice to see you too .
[doctor] so i know my nurse told you a little bit of- ... um , about dax and i'm gon na tell dax a little bit about you , if that's okay ?
[patient] go for it .
[doctor] okay , great . um , uh , this is christine . she's a 63-year-old female patient . you're here for your routine , um , yearly exam . um , i know you have a history of high blood pressure and you've had some depression in the past . and i also know you did have a carpal tunnel release done about two years ago . um , how have you been doing ?
[patient] i've been doing well . um , the depression standpoint is doing great . i've been using , um , the medication you prescribed me last time and going to therapy every week . and that's really helped me manage .
[doctor] okay . and you're sleeping well at night ? and everything's been going well from that standpoint ?
[patient] yeah , i've been getting a full eight hours .
[doctor] okay . and no thoughts of hurting yourself or anything like that ?
[patient] no .
[doctor] okay , good . um , and , um , i- i know you've had some high blood pressure in the past . have you been checking your blood pressure ?
[patient] i have . it's been a little bit up and down-
[doctor] okay .
[patient] lately , i have n't had a normal , um , normal reading- reading in a couple of weeks . um , it's either been high or low . um , has n't really stayed put .
[doctor] has n't really stayed put ?
[patient] yeah .
[doctor] okay . and , um , you've been talking your medication though , right ?
[patient] yes , i have .
[doctor] okay .
[patient] my diet's been a little all over the place . i have been really stressed with work and putting in more hours, so you know, it has been hard. i have not had time to go to the grocery store, let alone prepare and cook meals. so, i have been eating a lot of frozen meals.
[doctor] okay .
[patient] that type of thing .
[doctor] and have you had any headaches or swelling or anything like that that's been abnormal ?
[patient] i have some headaches but i just thought that was looking at a computer screen all day .
[doctor] okay , well , that's fair .
[patient] yeah , exactly .
[doctor] okay good . and , um ... i know my nurse did a review of systems . other than what we've just talked about , has there been anything else that you wanted to add to that ?
[patient] um , my carpal tunnel release has been doing well . on , uh , we did that , i think it was two years ago now .
[doctor] okay .
[patient] uh , on my right , um , wrist , and that's been great .
[doctor] great , great . no numbness or tingling in your hands ?
[patient] no .
[doctor] fingers ? okay , good . all right , well , um , lem me do a quick exam if that's okay ?
[patient] okay .
[doctor] deep breath . squeeze my fingers for me . feel me touch you here ?
[patient] yup .
[doctor] can you touch down here ?
[patient] mm-hmm .
[doctor] can you push your leg out ? push this one up . pull it back . yeah , good . okay . so on my exam , um ... your exam's essentially normal , your lungs are clear , are- ... you do n't have any adenopathy in your neck , you do n't have any , um , uh , hyperthyroidism . um , your heart is regular without any murmurs . um , your grips are equal , neurologically intact , strength is good , pulses are good . so overall , um , your exam is fine . let's take a- a look at some of your labs and vital signs .
[patient] okay .
[doctor] hey Sarah , show me the blood pressure . okay , so here in the office today it is a little bit elevated , okay ? so your blood pressure is a little bit high . so the results , um , do show that . um , hey Sarah , show me the labs . okay , so good news is is your- your labs are all essentially normal , so the results of your labs are essentially normal , okay ? so ... um , my assessment is that your- ... you do have hypertension still . um , and i think we need to increase your blood pressure medicine a little bit , okay ? so i'm gon na increase your lisinopril to 10 milligrams a day , just once a day , um , but i'm gon na increase that a little bit , okay ? and then want you to check it and i'm gon na have you come back in a month and we'll see how you're doing with regards to that , okay ?
[patient] okay .
[doctor] um , your second problem is your dep- depression , you're doing great , i do n't wan na change anything at this point . let's just stay- ... we'll change one thing with your high blood pressure-
[patient] mm-hmm .
[doctor] so i do n't wan na change any other medications at this point in time , so let's just leave that as it is .
[patient] okay .
[doctor] and then your third problem was your carpal tunnel . that seems to be doing well . if you notice any tingling or any changes or you get some of those symptoms back , just let me know . okay ?
[patient] okay .
[doctor] all right . anything else i can do for you today ?
[patient] no , that's it .
[doctor] okay . great . uh , lem me get you checked out .
[patient] okay .
[doctor] hey Sarah , finalize the report .

CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

Christine Flores is a 63-year-old female presenting for her yearly exam. She has a history of high blood pressure and depression in the past. She also had a right carpal tunnel release done about 2 years ago.

The patient states that she has been doing well with her depression. She notes that she has been taking her medication as prescribed at her last visit. She states that she has been going to therapy every week, which has helped her manage her symptoms. The patient notes that she is sleeping well at night and has been getting a full 8 hours. She denies any thoughts of self-harm or harming others.

The patient states that she has been checking her blood pressure at home. She notes that her blood pressure has fluctuated lately. She states that she has not had a normal reading in a couple of weeks. The patient has continued utilizing her medications.

She states that her diet has been a little all over the place. The patient notes that she has been working more hours. She reports that she has had some headaches, however, she thought that it was related to her increased screen time.

The patient states that her right carpal tunnel release has been doing well. She denies numbness or tingling in her hands or fingers.

REVIEW OF SYSTEMS

• Cardiovascular: Endorses blood pressure issues.
• Neurological: Endorses headaches.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Neurological/Psychological: Appropriate mood and affect. Bilateral grip strength equal. Neurologically intact.
• Neck: Supple without thyromegaly or cervical lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.

VITALS REVIEWED

• Blood Pressure: Elevated.

RESULTS

Laboratory studies are all within normal limits.

ASSESSMENT AND PLAN

Christine Flores is a 63-year-old female presenting for her yearly exam.

Depression.
• Medical Reasoning: She is doing well and managing this with medication and weekly therapy.
• Medical Treatment: Continue current regimen.

Hypertension.
• Medical Reasoning: Her blood pressures have been fluctuating lately. She does admit to dietary indiscretion due to her increased workload.
• Medical Treatment: Increase lisinopril to 10 mg once daily.
• Patient Education and Counseling: She should continue to monitor this at home and follow up in 1 month.

Carpal tunnel release.
• Medical Reasoning: She is doing well 2 years postoperatively and is asymptomatic at this time.
• Patient Education and Counseling: She will contact us if her symptoms return.

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