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Annual physical — hand osteoarthritis and anxiety screening

Van Loren O'Reilly · 42y · male · 2019-07-25

General examination of patient (procedure)

Chart background

Active conditions

  • Educated to high school level (finding)
  • Localized, primary osteoarthritis of the hand (disorder)
  • Body mass index 30+ - obesity (finding)
  • Medication review due (situation)
  • Stress (finding)

Active medications

  • Naproxen sodium 220 MG Oral Tablet

After-visit summary

Visit summary

What we discussed
• Stress with moderate anxiety symptoms
• Localized primary osteoarthritis of the hand
• Low HDL cholesterol
• Dental health
• Medication review due
• Health maintenance

Next steps
• Behavioral plan discussed: brisk 20-30 minute walks most evenings; scheduled daily worry time for budgeting.
• Provided information for sliding-scale counseling; patient will consider — not saying no.
• No medication initiated today; return in 2-3 months to reassess, sooner if worry disrupts sleep nightly or chest tightness escalates.
• Continue naproxen sodium 220 mg as needed, always with food; monitor for GI symptoms.
• Taught tendon-glide exercises and morning warm soaks; pace gripping tasks where possible.
• Regular aerobic activity as above; recheck lipids at next annual visit.
• Patient referral for dental care placed to a sliding-scale clinic; patient agreeable.
• Medication reconciliation completed: naproxen sodium 220 mg PRN is the only agent; use pattern appropriate.

deterministic_extractive_v1 · not_clinically_reviewed

Clinical note

**Subjective:** Van O'Reilly is a 42-year-old man presenting for a general adult examination, his first in several years, at his wife's insistence. Two main concerns: aching hands and persistent worry. Hands: known localized primary osteoarthritis of the hand with aching of the knuckles that has crept up gradually; worst at the end of ten-hour picker shifts at a distribution center (gripping totes, scanning) with morning stiffness that eases with activity. Pain 3/10 today, up to 5/10 after long shifts. No joint swelling, warmth, erythema, locking, or dropping objects. Naproxen sodium 220 mg once or twice weekly with food gives good relief; no dyspepsia, no melena. Stress: significant financial strain since his wife's work hours were cut — household of three with a young daughter — with nocturnal rumination over the budget, daytime muscle tension, irritability at work, and worry-associated (non-exertional) chest tightness. Stairs and heavy work provoke no symptoms. Mood is preserved: he enjoys his daughter's soccer games and garage projects, appetite and daytime energy intact; sleep is reduced by rumination. Denies hopelessness and any thoughts of self-harm. Also reports a lower-left molar sensitive to cold; no dental care in many years due to cost. ROS otherwise negative: no exertional chest pain, palpitations, dyspnea, fever, GI bleeding symptoms, or unintentional weight change. Never-smoker; alcohol about two beers on Saturdays; no other substances. Only medication: naproxen sodium 220 mg oral tablet as needed. No known allergies.

**Objective:** Vitals: BP 102/78 mmHg, HR 74/min, RR 15/min, height 162.1 cm, weight 73.5 kg, BMI 27.96 kg/m2, reported pain 3/10. Exam: well-appearing, animated, in no distress. Heart regular without murmur; lungs clear. Hands with bony fullness and mild tenderness over several finger joints, without swelling, warmth, or erythema; grip strong and functional. Posterior lower-left molar tender per patient report on gross oral inspection; no facial swelling. Lipid panel: total cholesterol 157.54 mg/dL, triglycerides 134.84 mg/dL, direct LDL 101.02 mg/dL, HDL 29.55 mg/dL. Screening scores: GAD-7 total 12; PHQ-2 total 5; PHQ-9 total 4; AUDIT-C total 2.

**Assessment and Plan:**

### Stress with moderate anxiety symptoms
GAD-7 of 12 (moderate) with a clear financial stressor, tension symptoms, and worry-related chest tightness; assessment of anxiety completed. Depression screening: PHQ-2 of 5 prompted full PHQ-9, which scored 4 — minimal depressive symptoms with mood, interest, and function preserved; no suicidal ideation.
- Behavioral plan discussed: brisk 20-30 minute walks most evenings; scheduled daily worry time for budgeting.
- Provided information for sliding-scale counseling; patient will consider — not saying no.
- No medication initiated today; return in 2-3 months to reassess, sooner if worry disrupts sleep nightly or chest tightness escalates.

### Localized primary osteoarthritis of the hand
Occupational aggravation with a benign exam — bony changes without inflammation.
- Continue naproxen sodium 220 mg as needed, always with food; monitor for GI symptoms.
- Taught tendon-glide exercises and morning warm soaks; pace gripping tasks where possible.

### Low HDL cholesterol
Lipid panel otherwise reassuring (total 157.54, LDL 101.02, triglycerides 134.84 mg/dL) with HDL low at 29.55 mg/dL.
- Regular aerobic activity as above; recheck lipids at next annual visit.

### Dental health
Cold-sensitive lower molar with years-long gap in dental care driven by cost.
- Patient referral for dental care placed to a sliding-scale clinic; patient agreeable.

### Medication review due
- Medication reconciliation completed: naproxen sodium 220 mg PRN is the only agent; use pattern appropriate.

### Health maintenance
- Immunizations administered today: influenza (split virus, trivalent, preservative-free); Td (adult) booster; hepatitis A (adult).
- Assessment of substance use and AUDIT-C (total 2) unremarkable; lifelong never-smoker.
- Assessment of health and social care needs completed; financial strain noted with low-cost resources provided.

FHIR resources at this visit

Observation 17Procedure 9DiagnosticReport 6Immunization 3Condition 2

Transcript

DRThere he is — Van O'Reilly, in the flesh. Sit down, man. It has been, what, three years?

PTAt least. And I will be honest right up front, Doc: I am here because Shauna booked the appointment, drove me over, and is currently sitting in the parking lot making sure I do not bolt.

DRMarried men live longer, and this is exactly why. Well, since you are captive — anything actually bothering you, or are we doing the full once-over?

PTFull once-over, I guess. But if I had to name things: my hands, and my head. Not the head like headaches — the head like it will not shut up.

DRHands first, then. What are they doing?

PTAching. The knuckles mostly. You told me a while back it was osteoarthritis, and it has been creeping. I am a picker at the distribution center — ten hours of gripping totes and scanning — and by end of shift my fingers feel like rusty hinges. Mornings they are stiff until the coffee kicks in.

DRHow bad right now, zero to ten?

PTRight now, a three. End of a Friday shift, a five maybe.

DRAny swelling? A joint that gets hot or red? Locking up, dropping things?

PTNo dropping, no hot or red. Just that deep ache. The naproxen helps — the over-the-counter 220s. One, maybe two a week, with food, like you said last time.

DRAny stomach burning with it? Black stools, anything like that?

PTNo, none of that. I am careful. Shauna reads the warning labels out loud at me like I am on trial.

DRKeep her. And keep taking it with food, keep it occasional exactly like you are doing. Before you leave I will show you some hand exercises — tendon glides, and a warm soak in the morning to loosen the hinges. Boring, but they work. Now — the head that will not shut up. Tell me.

PTMoney, mostly. Shauna's hours got cut in the spring. We have Ellie in second grade, so we are one income and change now, and I lie there at midnight running numbers. Rent, the truck, school stuff, groceries. Round and round. I am tense all day — shoulders up around my ears, snapping at guys at work over nothing. And sometimes my chest gets tight. Not pain. Tight, like a band.

DRTight with exertion — climbing stairs, hauling totes? Or tight when the worry spins up?

PTWhen the worry spins up. Stairs I do all shift, no problem. It is when the numbers start going round.

DRThat pattern matters — that sounds like anxiety, not your heart. And the forms from the lobby back it up. The worry questionnaire, the GAD-7 — you scored a 12, which lands in the moderate range. That is not Van-is-broken. That is the-load-is-real, and the alarm system is stuck in the on position.

PTStuck on. Yeah. That is exactly it. It does not switch off even when nothing is wrong that exact minute.

DRNow, the mood questions. The short screener flagged you — a 5 — so I want to walk through the longer one together, the nine-question version, because the short one casts a wide net on purpose. Little interest or pleasure in doing things?

PTNot really. I still like my stuff. Ellie's soccer games. My garage projects.

DRFeeling down or hopeless? Sleep? Appetite? Energy?

PTDown, no. Sleep is thin because of the number-spinning. Appetite is fine — too fine. Energy is decent once I am moving.

DRSo on the full version you come out at a 4, which is minimal. Here is what that tells me: your mood is holding — you still enjoy things, you are eating, functioning — but the worry channel is turned way up. Worry, not depression.

PTThat sounds right. I am not sad. I laugh plenty. I am just braced all the time. Like waiting for a shelf to come down.

DRBraced is a good word. I do have to ask directly: any dark thoughts? Hurting yourself, feeling like it is not worth it?

PTNo. God, no. I have too much to stick around for. That is half the problem — I care about all of it so much.

DRLoud and clear, and I am glad. So here is what I have for a stuck alarm. First, the free stuff: your body burns worry off with movement, and yours is built for it. A brisk walk after dinner, twenty or thirty minutes, most days — take Ellie on her bike. Second, a trick that sounds dumb and works: schedule the worry. Fifteen minutes, same time every evening, pen and paper, do all the budgeting then. When it starts up at midnight, you tell it — you had your slot.

PTSchedule the worry. Shauna is going to love that one.

DRThird: there is a counseling center over on Fairview that runs a sliding scale — you pay what your income allows. A few sessions to learn the tools is the most effective thing on this whole list.

PTMan, I do not know. Sitting in a room talking about feelings... but the sliding-scale part helps. Money being the whole problem, it would be dumb if the fix cost money. Let me look at it. I am not saying no.

DRNot saying no is plenty for today. And no medicines for this today either — that is not where we are, and honestly the walking might beat a pill anyway. But if the worry starts eating your sleep every night, or that chest tightness ramps up, you come back sooner and we talk options. Deal?

PTDeal.

DRDrinking okay? The form had you low — a 2 on the alcohol score.

PTSaturday, watching the game. Two beers, tops. Beer is not free either, Doc.

DRCheapest health plan there is. Never smoked, right? Okay — exam time. Deep breaths for me... good. Blood pressure is 102 over 78 — excellent. Pulse 74, breathing 15. You are 162.1 centimeters and 73.5 kilos, which works out to a BMI just under 28 — you are actually down from where the chart had you.

PTThat is the job. Ten hours a day walking concrete. Best gym membership I never asked for.

DRHeart and lungs sound great. Give me the hands — I can feel that bony fullness at a few of the knuckles, little tender when I press, but no swelling, no heat, and your grip is strong. That is the arthritis being itself, nothing angrier. Now open up for a second — you put a tooth on the intake form?

PTYeah. Lower left, in the back. Twinges on cold drinks. I have not sat in a dentist's chair since Ellie was born, honestly. It kept losing the budget vote.

DRI can see why it is talking to you back there. I am putting in a dental referral — and the clinic I refer to runs sliding scale too, same deal as the counseling place. Teeth are health, not luxury. Do not give it another year.

PTIf it is sliding scale, Shauna will have me in the chair by Tuesday.

DRGood. Your labs from last week: the cholesterol picture is mostly fine — total 157.54, LDL 101.02, triglycerides 134.84. The one soft spot is the HDL, the protective one — 29.55, and we like that higher. Want to guess what raises HDL?

PTLet me guess. Walking after dinner.

DRYou are my easiest patient all day. Last thing: shots. You are due for three, and we can knock them all out today. The flu vaccine. Your tetanus booster — you are overdue, and you work in a warehouse full of splinters and steel edges. And hepatitis A, which your generation mostly never got as kids.

PTThree needles. Shauna is going to think I got mugged in here.

DRTell her it was buy-two-get-one. The nurse will do them before you go — one arm or split them up, dealer's choice. Now recap for me. What are you leaving with?

PTWalk after dinner. The worry gets an appointment. Actually look at the counseling place — really look, not pretend-look. Naproxen with food, hand exercises, warm soaks. The dentist. Three shots. And come back if the head gets louder.

DREvery item, first try. Come back in two or three months regardless, just to tell me which way the worry is trending. And Van — everything is tight and you are still coaching the budget, walking Ellie to school, and showing up here. You are doing better than you give yourself credit for.

PT...Thanks, Doc. That one goes in the pocket for midnight. Alright. Send in the needles.