DIALOGUE

[doctor] and why is she here ? annual exam . okay . all right . hi , sarah . how are you ?
[patient] good . how are you ?
[doctor] i'm good . are you ready to get started ?
[patient] yes , i am .
[doctor] okay . so sarah is a 27-year-old female here for her annual visit . so , sarah , how have you been since the last time i saw you ?
[patient] i've been doing better . um , i've been struggling with my depression , um , a bit more just because we've been trapped really inside and remotely over the past year , so i've been struggling , um , off and on with that .
[doctor] okay . uh , and from looking at the notes , it looks like we've had you on , uh , prozac 20 milligrams a day .
[patient] yes .
[doctor] are , are you taking that ?
[patient] i am taking it . i think it's just a lot has been weighing on me lately .
[doctor] okay . um , and do you feel like you need an increase in your dose , or do you ... what are you thinking ? do you think that you just need to deal with some stress or you wan na try a , a different , uh , medication or ...
[patient] i think the , the medication has helped me in the past , and maybe just increasing the dose might help me through this patch .
[doctor] okay . all right . and , and what else has been going on with you ? i know that you've had this chronic back pain that we've been dealing with . how's that , how's that going ?
[patient] uh , i've been managing it . it's still , um , here nor there . just , just keeps , um , it really bothers me when i sit for long periods of time at , at my desk at work . so i have ... it helps when i get up and move , but it gets really stiff and it hurts when i sit down for long periods of time .
[doctor] okay , and do you get any numbing or tingling down your legs or any pain down leg versus the other ?
[patient] a little bit of numbing , but nothing tingling or hurting down my legs .
[doctor] okay , and does the , um , do those symptoms improve when you stand up or change position ?
[patient] yeah , it does .
[doctor] okay . all right . and any weakness in , in your legs ?
[patient] no , no weakness , just , just the weird numbing . like , it's , like , almost like it's falling asleep on me .
[doctor] okay . and are you able to , um , do your activities of daily living ? do you exercise , go to the store , that type of thing ?
[patient] yeah , i am . it bothers me when i'm on my feet for too long and sitting too long , just the extremes of each end .
[doctor] okay . and i know that you've had a coronary artery bypass grafting at the young age of 27 , so how's that going ?
[patient] yeah , i had con- i had a congenital ... you know , i had a congenital artery when i was a baby , so , um , they had to do a cabg on me , um , fairly young in life , but i've been ... my heart's been doing , doing well , and arteries have been looking good .
[doctor] okay . all right , well , let's go ahead and do a quick physical exam . um , so looking at you , you do n't appear in any distress . um , your neck , there's no thyroid enlargement . uh , your heart i hear a three out of six , systolic ejection murmur , uh , that's stable . your lungs otherwise sound clear . your abdomen is soft , and you do have some pain to palpation of your lumbar spine . uh , and you've had decreased flexion of your back . uh , your lower extremity strength is good , and there's no edema . so let's go ahead and look at some of your results . hey , dragon , show me the ecg . okay , so that looks basically unchanged from last year , which is really good . hey , dragon , show me the lumbar spine x-ray . hey , dragon , show me the back x-ray . great . so this looks good . that's also stable from last year . okay . so let's go ahead and , you know , my , my plan for you at this time , you know , from a chronic back pain standpoint , if you need , um , you know , some more physical therapy , and i can refer you to physical therapy to help with those symptoms that are kind of lingering .
[patient] mm-hmm .
[doctor] um , and we can always give you some pain medication if you , if you get some pain periodically with activity . how do you feel about that ? do you need some pain medication ?
[patient] no , i think physical therapy is the right way to , way to start out on this .
[doctor] okay . hey , dragon , order physical therapy referral . and then in terms of your depression , we talked about increasing your prozac , so we'll increase it from 20 milligrams to 40 milligrams . it's just one tablet once a day .
[patient] okay .
[doctor] um , and i'll send those to your pharmacy . does that sound okay ?
[patient] that sounds great .
[doctor] hey , dragon , order prozac , 40 milligrams , once a day . and then in terms of your ... the heart bypass that you've had ... let's go ahead and just order another echocardiogram for you , and i wan na continue you on the aspirin for now , okay ?
[patient] okay .
[doctor] hey , dragon , order an echocardiogram . hey , dragon , order aspirin 81 milligrams daily . okay , so the nurse will come in . she'll help you schedule those things , and we'll go from there , okay ?
[patient] okay .
[doctor] all right , take care .
[patient] thank you .
[doctor] hey , dragon , finalize the note .


CLINICAL NOTE

CHIEF COMPLAINT

Annual visit.

HISTORY OF PRESENT ILLNESS

The patient is a 27-year-old female who presents for her annual visit. The patient reports that she has been doing better since her last visit. She reports that she has been struggling with her depression off and on for the past year. The patient notes that it might be due been trapped inside and remotely over the past year. She reports that she is taking Prozac 20 mg, but she believes that it has been weighing on her lately. She notes that an increase in her Prozac dose might be beneficial for her at this time.

The patient reports that she has had chronic back pain that she has been managing. She reports that she experiences stiffness and pain when she sits or stands for long periods of time at her desk at work. She reports that it helps when she gets up and moves. She reports that she has a little bit of numbness down her legs, but no tingling or pain down her legs. She reports that the symptoms improve when she stands up or changes positions. She denies any weakness in her legs.

She reports that she has had a coronary artery bypass grafting. She reports that she had a congenital artery when she was a baby and they had to do a CABG on her fairly young age. She reports that her heart has been doing well and her arteries have been looking good.

REVIEW OF SYSTEMS

 Musculoskeletal: Endorses back pain.
 Neurological: Endorses numbness in legs.
 Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

 Constitutional: in no apparent distress.
 Neck: Supple without thyromegaly.
 Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
 Cardiovascular: 3/6 systolic ejection murmur, stable.
 Musculoskeletal: Pain to palpation of the lumbar spine. Decreased flexion of back. Lower extremity strength is good.

RESULTS

Echocardiogram appears unchanged in comparison to last year.

X-rays of the lumbar spine stable in comparison to last year.

ASSESSMENT

The patient is a 27-year-old female who presents today for an annual followup of chronic conditions.

Chronic back pain.
 Medical Reasoning: She is experiencing worsened pain with sitting for extended periods of time.
 Medical Treatment: Physical therapy referral ordered. Patient would like to defer pain medication at this time.

Depression
 Medical Reasoning: The patient was previously doing well on Prozac 20 mg once daily but feels as though she needs a higher dose at this time.
 Medical Treatment: Increase Prozac to 40 mg once daily. Prescription submitted.

History of coronary artery bypass graft.
 Medical Reasoning: She is doing well at this time. We will continue to monitor this.
 Medical Treatment: Echocardiogram ordered. Continue aspirin 81 mg daily.