General exam — chronic low back pain and positive depression screen
Emory Britt Kovacek · 22y · male · 2021-04-06
General examination of patient (procedure)
Chart background
Active conditions
- History of appendectomy (situation)
- Chronic pain (finding)
- Chronic low back pain (finding)
- Received higher education (finding)
- Stress (finding)
- Gingivitis (disorder)
Active medications
- Ibuprofen 400 MG Oral Tablet [Ibu]
After-visit summary
Visit summary What we discussed • Chronic low back pain • Stress with depressive symptoms • Gingivitis • Elevated blood pressure reading • Preventive care and screening Next steps • Ibuprofen 400 mg oral tablet prescribed; take with food as needed for flares. • Activity counseling: hourly breaks from sitting, daily walking, hip-hinge lifting mechanics. • Reassess at 4-week follow-up. • Counseling resource list provided (including telehealth options); patient agreed to review. • Behavioral activation counseling: fixed wake time, morning light, daily movement, scheduled social contact. • Repeat PHQ-9 at 4-week follow-up; discuss therapy and further options if not improving. Crisis-line information provided with explicit same-day return precautions. • Patient referral for dental care placed for cleaning and examination. • Daily flossing and twice-daily brushing counseled.
deterministic_extractive_v1 · not_clinically_reviewed
Clinical note
**Subjective:** Emory Kovacek is a 22-year-old man presenting for a general examination, his first in several years, with a concurrent flare of chronic low back pain. The pain is a dull band across the lower lumbar region, currently 4/10, dating to a lifting episode in college and clearly aggravated by prolonged sitting during work crunches as a software QA tester. It improves with walking and heat. He denies radicular symptoms, numbness, weakness, bowel or bladder dysfunction, night pain, fevers, and weight loss. He previously used ibuprofen with good effect but has none at home. Depression screening was notably positive: he endorses anhedonia and low mood most days since winter, initial insomnia, low energy, reduced appetite, intermittent guilt, poor concentration, and restlessness, in the context of work crunch and his girlfriend's cross-country move. He explicitly and credibly denies thoughts of death or self-harm. He remains functional at work. Domestic safety screen negative. Substance history: cannabis edible twice this past winter for pain/sleep, otherwise none; never smoked; occasional alcohol. Surgical history: appendectomy in adolescence. No medications; no known allergies. **Objective:** Vitals: BP 136/94 mmHg, HR 89/min, RR 15/min, weight 77 kg, height 185.2 cm, BMI 22.46 kg/m2, pain score 4/10. Exam: Well-appearing, calm, appropriate affect; engages readily. Lumbar exam: bilateral paraspinal tightness without midline tenderness; flexion mildly limited by stiffness; straight-leg raise negative bilaterally; lower-extremity strength, sensation, and reflexes intact. Gait normal. Oral exam: erythematous, edematous gingival margins consistent with gingivitis. Well-healed right lower quadrant surgical scar. Screenings: PHQ-2 total 5; PHQ-9 total 17 (moderately severe range; item 9 negative). HARK total 0. DAST-10 total 1. PRAPARE: 3-person household; reported annual family income $91,796. **Assessment and Plan:** ### Chronic low back pain Mechanical, muscular pattern without red flags, aggravated by prolonged sitting; exam without neurologic deficit. - Ibuprofen 400 mg oral tablet prescribed; take with food as needed for flares. - Activity counseling: hourly breaks from sitting, daily walking, hip-hinge lifting mechanics. - Reassess at 4-week follow-up. ### Stress with depressive symptoms PHQ-2 of 5 reflexed to PHQ-9 of 17, moderately severe symptom burden in the setting of occupational crunch and social isolation; no suicidal ideation; functioning preserved. Documented as stress; will track closely. - Counseling resource list provided (including telehealth options); patient agreed to review. - Behavioral activation counseling: fixed wake time, morning light, daily movement, scheduled social contact. - Repeat PHQ-9 at 4-week follow-up; discuss therapy and further options if not improving. Crisis-line information provided with explicit same-day return precautions. ### Gingivitis Gingival erythema and edema with bleeding on flossing. - Patient referral for dental care placed for cleaning and examination. - Daily flossing and twice-daily brushing counseled. ### Elevated blood pressure reading Single office reading of 136/94 mmHg, possibly contextual (pain, clinic setting); family history of hypertension noted. - Recheck blood pressure at 4-week visit; no treatment today. ### Preventive care and screening Domestic abuse screening negative (HARK 0); drug abuse screening low risk (DAST-10 score 1); never-smoker. Medication reconciliation and assessment of health and social care needs completed. - Follow-up visit in 4 weeks: back pain, blood pressure recheck, and PHQ-9 re-screen.
FHIR resources at this visit
Transcript
DREmory? Come on back. I'm Dr. Reyes. Have a seat wherever. How's it going?
PTFine. Good, I mean. Fine.
DRTwo fines and a good — solid opening. It says you booked a general exam. Anything specific on your mind, or just due for a once-over?
PTMostly due. I haven't really been to a doctor since college. And my back's been acting up again, so I figured I'd bundle it.
DREfficient. Tell me about the back.
PTIt's the same low back thing I've had for a few years. Junior year I helped basically my roommate's entire floor move out in one day — couches, a mini fridge, somebody's weight set. Felt something pull. It never totally un-pulled, if that's a word.
DRHow would you describe it now — where, what kind of pain?
PTA dull band across the very bottom of my back. Right now it's like a four out of ten. Desk days make it worse. I do QA testing for a software company, so when a release is close it's ten hours in a chair, and by Friday I'm walking like a question mark.
DRDoes it ever shoot down a leg? Numbness, tingling, weakness in the feet?
PTNo, nothing like that. It stays in the back.
DRAny trouble with bladder or bowels, fevers, night pain that wakes you, weight loss?
PTNo. It's boring pain. Reliable, boring pain.
DRBoring is actually good news with backs. What helps?
PTWalking. Hot showers. I had ibuprofen for a while, which worked, but the bottle ran out months ago and I never dealt with it.
DROkay, we'll deal with it today. Let's do the general once-over questions. You had your appendix out as a teenager, right?
PTYeah, when I was fifteen. That's my only surgery. I've still got the scar and a mild distrust of gas station food.
DRReasonable takeaways. Any medications at all right now?
PTNothing. The empty ibuprofen bottle doesn't count, I assume.
DRIt counts as a plot point. Allergies?
PTNone.
DRSmoking, vaping?
PTNever. Neither.
DRAlcohol?
PTOccasionally. A beer with the roommates on weekends, if that.
DRGot it. This is also a screening visit, so everybody gets the questionnaires — mood, safety, substances. Some are personal; answer as honestly as you're comfortable. First one: over the last two weeks, how often have you had little interest or pleasure in doing things?
PT...Honestly? More than half the days. Probably most days.
DRFeeling down, depressed, or hopeless?
PTYeah. Most days, kind of a gray filter over everything. I figured it was just winter that never gave the keys back.
DRI appreciate you being straight with me — that answer flags the longer version, nine questions, same idea. Trouble falling asleep, staying asleep, or sleeping too much?
PTFalling asleep, nearly every night. My brain does release retrospectives at 1 a.m.
DRFeeling tired or having little energy?
PTNearly every day. Which I always blamed on the sleep thing.
DRPoor appetite or overeating?
PTI forget lunch more than half the time. Not on purpose.
DRFeeling bad about yourself — that you're a failure or have let people down?
PTSome days. Several, I guess.
DRTrouble concentrating on things like reading or screens?
PTMore than half the days, which is awkward, because concentrating on screens is the whole job.
DRMoving or speaking slowly, or the opposite — fidgety, restless?
PTRestless, several days. I bounce my knee enough that my deskmate filed a complaint. A friendly one.
DRLast one, and I ask everyone directly: thoughts that you'd be better off dead, or of hurting yourself in any way?
PTNo. Never that. I want to be really clear on that one — no.
DRI'm glad, and I believe you. Adding it up, you score a 17, which lands in the moderately severe range for depressive symptoms.
PTSeventeen sounds like a lot when you say it out loud.
DRIt's a number that says this deserves real attention — not a verdict, not a personality. How long has the gray filter been running?
PTSince winter, maybe? Work went into crunch — we shipped two releases back to back — and my girlfriend moved across the country for grad school in January, so evenings got really quiet. I figured it was stress. It is stress, mostly. I still function. I hit my deadlines.
DRFunctioning and struggling aren't opposites — plenty of people do both at once, and you're describing textbook load: crunch, long-distance, isolation, bad sleep, back pain. Here's what I'd like to offer. One: counseling — a therapist is the best-studied tool for exactly this picture. I can give you a list that works with your insurance, including a couple that do evening telehealth.
PTI'm not really a talk-about-it guy. Clearly.
DRAnd yet you just did it pretty well for ten minutes. I'm not going to force anything — you're safe, you're functioning, and this is your call. My ask is smaller: take the list, actually look at it, and come back in four weeks so we can re-score this and see the trend. If it's not budging, we talk options again — therapy, and there are medication options too if it ever comes to that. Nothing today unless you want it.
PTFour weeks and a list. That I can do.
DRMeanwhile, the boring powerful stuff: a fixed wake time even after bad nights, daylight in the morning, movement every day — your back will thank you too — and schedule the girlfriend calls like meetings so the quiet evenings have an anchor.
PTShe'd actually love that. She lives by her calendar.
DRTwo more screens and we're done with questions. These I ask everyone: at home or in any relationship, is anyone humiliating you, making you afraid, hurting you physically, or forcing anything?
PTNo. Nothing like that. We're long-distance but we're good, and the roommates are fine.
DRGood — that screen is a zero. Substances: any drug use in the past year? Cannabis, pills not prescribed to you, anything else?
PTA friend gave me a gummy once this winter when my back was bad and I couldn't sleep. Twice, total, honestly. Didn't love it, didn't repeat it.
DRThanks for the honesty — that puts you at a one out of ten on the drug screen, which is low, and nothing there worries me. I'd rather give your back better tools anyway. Hop up on the table, let me examine you. Bend forward as far as comfortable... side to side... okay. Your low back muscles are tight on both sides, but the spine itself isn't tender, leg raises don't reproduce anything, strength and reflexes are all normal. That's a muscular, mechanical picture — consistent with the desk marathons.
PTBoring, reliable pain, like I said.
DROne number I want you to know about: your blood pressure today is 136 over 94, which is higher than I want to see at twenty-two. One reading doesn't mean much — pain, coffee, and clinics all push it up — so we'll recheck at the four-week visit rather than react today. Heart rate's 89, everything else looks great, and at 77 kilos your BMI is 22.5, dead normal.
PTHuh. Okay. My dad has blood pressure stuff, so... noted.
DRGood to know, and all the more reason to just track it. Now, back plan: I'm prescribing ibuprofen 400 milligrams — take one with food when it flares, not on an empty stomach. It's the refill of your expired strategy, but legitimate this time. Plus the unglamorous part: out of the chair every hour, even five minutes. Walk at lunch. When you lift — hinge at the hips, keep the load close.
PTMy watch already yells at me to stand. I ignore it professionally.
DRNew policy: the watch outranks you. Last thing — open your mouth for me? Your gums are red and puffy along the edges, and I'd bet they bleed when you floss.
PTWhen I remember to floss. Which is when it bleeds. Which is why I don't. It's a vicious cycle.
DRClassic gingivitis loop. It reverses with a real cleaning and daily flossing — the bleeding stops once the gums calm down, usually a couple of weeks. I'm sending a dental referral today.
PTMy hygienist ghost-writes my guilt already. Fine. Dentist, list, four weeks.
DRPerfect summary. And Emory — if the gray filter ever gets darker than what you told me today, especially anywhere near that last question I asked, you call us same-day or use the crisis line on the sheet. That's not a formality.
PTUnderstood. For real. Thanks for not making this weird.
DRMaking it not-weird is most of the job. Front desk will book the four-week recheck — back, blood pressure, and mood score, all three.
PTThe trilogy. See you in four weeks.