[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 .
ASSESSMENT AND PLAN

Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.
 
 Upper respiratory infection.
 • Medical Reasoning: I believe he has contracted a viral syndrome. His chest x-ray was unremarkable and he has received both doses of the COVID-19 vaccination.
 • Additional Testing: We will obtain a COVID-19 test to rule this out.
 • Medical Treatment: I recommend he use Robitussin for cough, as well as ibuprofen or Tylenol if he develops a fever.
 
 Depression.
 • Medical Reasoning: He has been practicing barre classes and is doing well overall.
 • Medical Treatment: I offered medication or psychotherapy, but the patient opted to defer at this time.
 
 Diabetes type 2.
 • Medical Reasoning: His blood glucose levels have been well controlled based on home monitoring, but his recent hemoglobin A1c was elevated.
 • Additional Testing: We will repeat a hemoglobin A1c in 4 months.
 • Medical Treatment: We will increase his metformin to 1000 mg twice daily.
 
 Hypertension.
 • Medical Reasoning: He has been compliant with lisinopril and his blood pressures have been well controlled based on home monitoring.
 • Additional Testing: We will order a lipid panel.
 • Medical Treatment: He will continue on lisinopril 20 mg once daily. This was refilled today.
 
 Follow up: I would like to see him back in approximately 4 months.
 
 