[doctor] hi , edward , how are you ? [patient] i'm doing well , yourself ? [doctor] i'm doing okay . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] absolutely . [doctor] edward is a 59 year old male with a past medical history significant for depression , hypertension and prior rotator cuff repair who presents for followup of his chronic problems . so , edward , it's been a little while since i saw you . [patient] mm-hmm . [doctor] how are you doing ? [patient] i'm doing pretty well , actually . it's been a good , uh , good six months . [doctor] good . okay . so , you know , the last time we spoke , you know , you were trying to think of some new strategies to manage your depression . you did n't wan na go on medication because you're already on a bunch of meds . [patient] absolutely . [doctor] so , how are you doing with that ? [patient] i'm doing well . i see a counselor , uh , once a week . uh , and i've been out swimming at the pool a lot this , this , uh , summer , and , uh , fall . so , things have been well , going well with my depression . [doctor] okay , so , you do n't wan na , you do n't feel the need to start any medications at this time ? [patient] no , no , no . but , i know i can call you if i do . [doctor] yeah , absolutely . [patient] okay . [doctor] yeah . all right . and then , in terms of your high blood pressure , how are you doing with that ? i know we , we were kind of struggling with it la- six months ago . how are you doing ? [patient] i still have my good days and my bad days . i do take my medicine daily . uh , but , you know that burger and wine , every once in a while , sneaks in there , and that salt be ... we know what that does . [doctor] yeah . so , i love burgers and wine too . [patient] okay . [doctor] so , i get it . um , okay , so , and you're taking the norvasc ? [patient] norvasc , yep . [doctor] okay . um , and , you're checking your blood pressures at home , it sounds like ? [patient] i , i do . well , i go to cvs pharmacy . they , they have a , uh , machine that i can sit down at quickly and get my , uh , blood pressure taken . and , i go there about once a week . [doctor] okay . all right . and then , i know that you had that rotator cuff repaired about eight months ago . how are you doing ? [patient] um , it's doing well . i , i'm , i'm , been stretching with a yoga ball . [doctor] uh- . [patient] and , uh , i'm getting stronger each time . and , i can continue that once a week also . [doctor] okay . are you still seeing the physical therapist in the center , or are you just doing exercises at home ? [patient] i'm just , i progressed to exercises at home . [doctor] okay . all right . great . all right . well , i know you did a review of systems sheet when you checked in . [patient] mm-hmm . [doctor] and , you know , it seems like you're doing well . any symptoms at all ? any nasal congestion or chest pain , shortness of breath , anything ? [patient] no . none of those . i do , do notice that i get a little bit of a de- , uh , swelling in my ankles . [doctor] okay . [patient] uh , mainly near the end of the day . [doctor] okay . [patient] um , it seems to go away by the next morning . [doctor] okay . all right . all right . maybe that has to do with some of the salt intake you're , you're eating . [patient] okay . [doctor] all right . well , i wan na go ahead and do a quick physical exam , okay ? [patient] mm-hmm . [doctor] hey , dragon ? show me the blood pressure . yeah , so , your blood pressure's a little elevated today , 156 over 94 . [patient] okay . [doctor] you know , you could be a little happy to see me . i do n't know .  [doctor] um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months . [patient] okay . [doctor] so , we'll have to just kinda talk about that , okay ? [patient] okay . [doctor] i'm gon na go ahead and listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] okay . [doctor] okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past . [patient] okay . [doctor] so , that seems stable to me . um , on your lung exam , everything sounds nice and clear , and on your lower extremity exam , i do appreciate , you know , 1 to 2+ pitting edema in your legs , okay ? so , we'll have to just talk a little bit about your diet and decreasing the salt intake , okay ? [patient] okay . [doctor] so , let me just look at some of your results , okay ? hey , dragon ? show me the labs . so , looking here at your lab results , everything looks really good . you know , your creatinine , that's your kidney function , that looks stable . everything looks good from that standpoint . hey , dragon ? show me the ekg . and , looking here at your ekg , everything , you know , looks fine . there's no evidence of any coronary artery disease . it's a nice , normal ekg , which is good . [patient] okay . [doctor] okay ? [patient] good . [doctor] so , let me just talk a little bit about my assessment and my plan for you . okay ? so , from a depression standpoint , it's , you know , your first problem , i think that that sounds like you're doing really well managing it . you know , you have good strategies . it sounds like you have a good support system , um , and i agree . i do n't think you need to start on any medication at this time , but you said before , you know you can call me , okay ? [patient] yes . [doctor] for your second problem , your hypertension , i , i do n't believe it's well controlled at this time . so , i wan na go ahead and , you know , increase the norvasc up to 10 mg a day , and i wan na go ahead and order an echocardiogram and a lipid panel , okay ? [patient] okay . [doctor] hey , dragon ? order an echocardiogram . and , for your third problem , your rotator cuff repair , i , i think you're doing really well with that . i would just continue with the exercises and , uh , i do n't think we need to intervene upon that anymore . it sounds like that's pretty much resolved , okay ? [patient] good . good . [doctor] do you have any questions about anything ? [patient] no questions . [doctor] okay , great . hey , dragon ? finalize the note .
ASSESSMENT AND PLAN

Edward Butler is a 59-year-old male with a past medical history significant for depression, hypertension, and prior rotator cuff repair. He presents for a follow-up of his chronic problems.
 
 Depression.
 • Medical Reasoning: He is doing well with therapy and physical activity. He continues to decline medication for this.
 • Medical Treatment: Continue current management strategies.
 • Patient Education and Counseling: I encouraged him to contact me should he want to try medication.
 
 Hypertension.
 • Medical Reasoning: This is uncontrolled at this time. He is compliant with Norvasc, but admits to occasional dietary indiscretion.
 • Additional Testing: We will order a lipid panel and an echocardiogram.
 • Medical Treatment: Increase Norvasc to 10 mg daily.
 
 8 months status post rotator cuff repair.
 • Medical Reasoning: He is doing well postoperatively. He has progressed from formal physical therapy to solely home exercise.
 • Medical Treatment: Continue with home exercise.
 
 