[doctor] hi , andrew . how are you ?
[patient] hey , good to see you .
[doctor] i'm doing well , i'm doing well .
[patient] good .
[doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ?
[patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse .
[doctor] okay . all right . um , now , have you had your covid vaccines ?
[patient] yeah , both .
[doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ?
[patient] none whatsoever .
[doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ?
[patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me .
[doctor] okay . and are you coughing up anything ?
[patient] not yet , but i feel like that's next .
[doctor] okay . and fevers ?
[patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself .
[doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ?
[patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags .
[doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ?
[patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working .
[doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ?
[patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part .
[doctor] okay and have they been elevated at all since this episode of your-
[patient] no .
[doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ?
[patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control .
[doctor] but you're taking your medication ?
[patient] yes .
[doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ?
[patient] no .
[doctor] anything like that ?
[patient] no .
[doctor] okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so , your vital signs here in the office look quite good .
[patient] mm-hmm .
[doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ?
[patient] sure .
[doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ?
[patient] mm-hmm .
[doctor] hey , dragon . show me the chest x-ray .
[doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ?
[patient] good .
[doctor] hey , dragon . show me the diabetic labs .
[doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight .
[patient] mm-hmm .
[doctor] i'd like to see that a little bit better , around six or seven , if possible .
[patient] mm-hmm .
[doctor] um , so let's talk a little bit about my assessment and my plan for you .
[patient] mm-hmm .
[doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid .
[patient] mm-hmm .
[doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing .
[patient] mm-hmm .
[doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ?
[patient] you got it .
[doctor] for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ...
[patient] mm-hmm .
[doctor] . refer you to psychotherapy , if you think that that would be helpful .
[patient] mm-hmm .
[doctor] would you like that ?
[patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that .
[doctor] okay . all right .
[doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily .
[patient] mm-hmm .
[doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ?
[patient] okay , sure .
[doctor] hey , dragon . order a hemoglobin a1c .
[doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day .
[patient] mm-hmm .
[doctor] and i'm gon na go ahead and order a lipid panel , okay ?
[patient] sure .
[doctor] do you need a refill of the lisinopril ?
[patient] actually , i do .
[doctor] okay . hey , dragon . order lisinopril , 20 milligrams daily .
[doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months .
[patient] okay .
[doctor] let me know if your symptoms worsen and we can talk more about it , okay ?
[patient] you got it .
[doctor] all right . hey , dragon . finalize the note .

Medical orders:
description: metformin 1000 milligrams twice daily
order_type: medication
reason: type two diabetes
description: hemoglobin a1c in four months
order_type: lab
description: lisinopril 20 milligrams a day
order_type: medication
reason: hypertension
description: lipid panel
order_type: lab
reason: hypertension
description: follow-up about four months
order_type: followup
description: covid test
order_type: lab
reason: i believe you , you have a viral syndrome
description: robitussin
order_type: medication
reason: cough
description: ibuprofen
order_type: medication
reason: fever
description: tylenol
order_type: medication
reason: fever