[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 , dragon , 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 , dragon , 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 , dragon , 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 , dragon , 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 , dragon , 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 , dragon , 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 , dragon , finalize the note . the nurse will be in . [patient] thank you .
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.
 
 