Annual check-up — post-sepsis recovery and prediabetes
Dick Larson · 36y · male · 2024-05-18
Encounter for check up (procedure)
Chart background
Active conditions
- Housing unsatisfactory (finding)
- Received higher education (finding)
- Prediabetes (finding)
- Body mass index 30+ - obesity (finding)
- Sepsis (disorder)
- Septic shock (disorder)
- Acute respiratory distress syndrome (disorder)
- Anemia (disorder)
- Medication review due (situation)
- Unemployed (finding)
- Social isolation (finding)
Active medications
None recorded
After-visit summary
Visit summary What we discussed • Prediabetes • Body mass index 30+ — obesity • Post-sepsis recovery (sepsis, septic shock, ARDS) and anemia • Unemployment, social isolation, and unsatisfactory housing • Medication review due • Preventive care and screening Next steps • Lifestyle counseling provided: goal of 5–7% weight loss and progressive daily walking. • Repeat A1c at follow-up in approximately 6 months. • Dietary moderation and graded aerobic activity as tolerated post-ARDS. • Weight recheck at follow-up. • Continue graduated activity; return precautions reviewed for fever, dyspnea, or declining stamina. • Continue longitudinal monitoring of anemia and fatigue trajectory. • Community resource sheet provided (employment center, tenant advocacy line). • Encouraged structured daily routine and social re-engagement; patient agreed to report mood changes.
deterministic_extractive_v1 · not_clinically_reviewed
Clinical note
**Subjective:** Dick Larson is a 37-year-old man presenting for a routine check-up, his first comprehensive outpatient visit since recovering from a hospitalization for sepsis complicated by septic shock and acute respiratory distress syndrome. He reports steadily improving stamina since discharge: he walks daily and tolerates level ground well but remains exertionally limited on hills and stairs. He denies fever, chills, night sweats, cough, chest pain, dyspnea at rest, palpitations, orthopnea, and leg swelling. Regarding his known anemia, he denies dizziness or pallor and notes his family feels his color has returned. He rates pain 1/10, attributed to intermittent low back ache with prolonged sitting. Interval social history is significant: he lost his logistics job in February after his prolonged medical leave and is unemployed for the first time in his adult life. He describes markedly reduced social contact since the illness, though household finances remain stable on his wife's income. He lives with five family members in a three-bedroom rental with delayed landlord maintenance and describes the housing situation as unsatisfactory and crowded. He denies persistent low mood or anhedonia. He has never smoked, drinks alcohol rarely, and denies any drug use. He takes no daily prescription medications; a medication review was due and completed today. No known allergies. **Objective:** Vitals: BP 107/69 mmHg, HR 63/min, RR 15/min, weight 84.4 kg, height 166.8 cm, BMI 30.34 kg/m2, pain score 1/10. Exam: Well-appearing, comfortable, conversant. Lungs clear bilaterally without increased work of breathing. Heart regular rate and rhythm. No conjunctival pallor. No lower extremity edema. Labs: Hemoglobin A1c 5.99%. Basic metabolic panel: glucose 86.7 mg/dL, BUN 13.78 mg/dL, creatinine 1.22 mg/dL, calcium 9.98 mg/dL, sodium 139.13 mmol/L, potassium 4.89 mmol/L, chloride 104.04 mmol/L, total CO2 28.05 mmol/L. Screenings: PHQ-2 total score 1. DAST-10 total score 0. PRAPARE completed: household of 6; reported annual family income $198,810. **Assessment and Plan:** ### Prediabetes A1c 5.99% remains in the prediabetic range with a normal fasting glucose of 86.7 mg/dL. - Lifestyle counseling provided: goal of 5–7% weight loss and progressive daily walking. - Repeat A1c at follow-up in approximately 6 months. ### Body mass index 30+ — obesity BMI 30.34 kg/m2 today. - Dietary moderation and graded aerobic activity as tolerated post-ARDS. - Weight recheck at follow-up. ### Post-sepsis recovery (sepsis, septic shock, ARDS) and anemia Functional recovery is progressing; no red-flag symptoms of recurrent infection. Renal indices reassuring after septic shock (creatinine 1.22 mg/dL). Known anemia is clinically asymptomatic today. - Continue graduated activity; return precautions reviewed for fever, dyspnea, or declining stamina. - Continue longitudinal monitoring of anemia and fatigue trajectory. ### Unemployment, social isolation, and unsatisfactory housing Newly documented unemployment and social isolation; ongoing unsatisfactory housing. Assessment of health and social care needs completed today. - Community resource sheet provided (employment center, tenant advocacy line). - Encouraged structured daily routine and social re-engagement; patient agreed to report mood changes. ### Medication review due Medication reconciliation completed; residual hospital entries removed. No active daily prescriptions. - Continue as-needed self-care only; revisit list at next visit. ### Preventive care and screening Depression screening negative (PHQ-2 score 1); drug abuse screening negative (DAST-10 score 0); never-smoker. Substance use assessment unremarkable. - Influenza vaccine (split virus, trivalent, preservative-free) administered today. - Follow-up visit in approximately 6 months, sooner for any concerns.
FHIR resources at this visit
Transcript
DRGood morning — Mr. Larson? Dick? Come on in, grab whichever chair looks least uncomfortable.
PTMorning, Doc. Dick's fine. Feels strange being in a clinic that isn't attached to an ICU, I'll say that.
DRI bet. I was reading through your chart before you came in. You had a rough stretch — the sepsis admission, septic shock, time on the ventilator with the ARDS. That's about as sick as a person gets. How have you been since discharge?
PTHonestly? Better than I was, worse than I'd like. Stairs still take something out of me. But I walk every day now. My daughter calls it my grandpa lap — once around the block, slow and dignified.
DRI will take a grandpa lap over a couch any day of the week. Any fevers since you got home? Chills, night sweats, anything that felt like an infection trying to come back?
PTNo, nothing like that. Knock on wood.
DRChest pain? Trouble breathing when you're just sitting still?
PTNo. I get winded on hills, and if I try to jog the dog gets embarrassed for me, but at rest I'm fine.
DRCough?
PTNot really. The lungs feel quieter than they used to, if that makes any sense.
DRIt does, and it fits — recovery from ARDS can take a full year, and you sound like you're tracking the right direction. They also found you anemic in the hospital. Any dizziness, racing heart, people telling you that you look pale?
PTThe opposite, actually. My wife says I finally got my color back around March. No dizziness.
DRGood. So today is a check-up in the proper sense — we'll go over your medication list, look at the bloodwork from this morning, run a few screening questionnaires, and talk about the bigger picture. Sound all right?
PTSure. I've got nowhere to be. Which is sort of the problem, actually.
DRSay more about that?
PTI got let go in February. Officially it was restructuring. Unofficially, I was out four months with the whole ICU adventure, and when I came back half my accounts had been handed off. Logistics doesn't wait around for you. So — unemployed. First time since I was sixteen years old.
DRI'm sorry. That's a real loss, on top of everything your body already went through. How are you filling the days?
PTJob applications, mostly. Some daytime television I'm not proud of. Money-wise we're okay — my wife's job carries the household fine, so it's not about the paycheck. It's that I used to talk to thirty people a day, and now I mostly talk to the dog. He's a poor conversationalist.
DRThat kind of isolation matters to your health as much as most things I can measure. Do you see friends? Family outside the house?
PTNot much anymore. The guys from work stopped calling around the time I stopped being useful to them. And the house is full — six of us, with the kids and my mother-in-law — but full and connected aren't the same thing, you know?
DRI do know. And how's the house itself treating you? Last visit there was a note that the housing situation was a strain.
PTIt's too small, plain and simple. Three bedrooms, six people. The landlord takes his sweet time with repairs — the bathroom fan has been dead since winter, there's a window that won't close right. We keep looking, but there's nothing decent in our range near the kids' school.
DROkay. Part of today's visit is a formal assessment of health and social care needs, so I'm going to document the housing situation and the job loss, and I'll have the front desk print our community resource sheet — there's an employment center and a tenant advocacy line on it. Not magic, but people do actually use them.
PTCan't hurt. Beats talking to the dog.
DRLet me run the screening questions. Over the past two weeks, how often have you been bothered by having little interest or pleasure in doing things?
PTA few days, I'd say. Not most days. Job hunting is a grind, but I still enjoy my kids, cooking, the ballgame.
DRAnd feeling down, depressed, or hopeless?
PTNot hopeless, no. Frustrated, absolutely. But not that.
DRThat puts you at one point out of six on the short mood screen, which is low — reassuring. But given the year you've had, I want a deal: if that changes, you tell me. Not the dog, me.
PTDeal.
DRSubstance questions — I ask everyone, every time. Any drug use in the past twelve months? Marijuana, pills that weren't prescribed to you, anything else?
PTNo. A beer at a barbecue is about as wild as I get these days.
DRTobacco, ever?
PTNever. My dad smoked enough for the entire family tree. Cured me before I started.
DRYour drug screening questionnaire comes out to a zero, so nothing to chase there. Now, medications — the chart flagged you as due for a medication review. What are you actually taking, day to day?
PTDay to day? Nothing regular. When I left the hospital they whittled the list down and then off entirely at the follow-ups. That's it.
DRSo no daily prescription medications at all right now.
PTCorrect. It's the emptiest my bathroom shelf has looked in a year.
DRThen I'll reconcile the list — it was still showing some hospital leftovers, and cleaning that up genuinely matters. Any medication allergies?
PTNone that anyone's ever found.
DRAll right, exam time. Deep breath for me... again... good. Heart sounds regular. Let me see the ankles... no swelling. Your blood pressure today is 107 over 69, which is excellent. Heart rate 63, breathing 15 times a minute, nice and easy. Any pain right now, zero to ten?
PTA one, maybe. The low back mutters when I sit too long. It's background noise.
DRNoted. Weight came in at 84.4 kilos, height 166.8, so the BMI works out to 30.34 — just over the obesity line. I mention it not to nag, but because it connects directly to the next thing. Your labs from this morning are back. The hemoglobin A1c — the three-month average of your blood sugar — is 5.99 percent. That keeps you in prediabetes territory.
PTStill? I half figured almost dying would have burned some sugar off.
DRHa — it stubbornly doesn't work that way. Here's the good news: your glucose today was 86.7, completely normal, and the rest of the metabolic panel looks solid. Sodium 139, potassium 4.89, chloride and bicarbonate fine. Kidneys came through at a creatinine of 1.22 with a BUN of 13.78 — I always double-check kidneys after a septic shock episode, and yours held up.
PTThat is genuinely good to hear. Kidneys were the daily topic in the ICU. That and my lungs.
DRThey took the hit and recovered. So prediabetes is the one thing on this panel we can still steer. Normal A1c is under 5.7; you're at 5.99. Five to seven percent weight loss — for you that's roughly four to six kilos — plus stretching that daily walk out, and this number very often drifts back to normal.
PTSo the grandpa laps get longer.
DRLonger and more frequent. I'd rather see thirty minutes most days than one heroic hour on Saturday. And frankly, a daily walking routine will help the job-hunt brain too. Structure is going to be your friend this year — for the sugar, the weight, and the mood.
PTStructure. I used to schedule forty truck routes a day. I suppose I can schedule myself.
DRThat's the spirit — you're the last remaining account, manage yourself well. One more housekeeping item: you missed your flu shot in the fall, and I'd like to get you covered while you're here. Any bad reaction to flu vaccines before?
PTNo, I just forget them. Fine. Which arm do they want?
DRThe nurse will sort that out — it's the standard trivalent one, sore arm for a day at most. So, the summary: prediabetes — lifestyle push, recheck the A1c in about six months. Weight — aiming for that five percent. The anemia from the hospitalization — you look well and have no symptoms, we'll keep following it. Job, housing, isolation — resource sheet today, and you keep me honest about your mood. Flu shot before you leave. Questions for me?
PTJust one. The tiredness — is that the anemia, the lungs, or the unemployment?
DRTruthfully? Probably a share of each, and all three should keep improving. If the fatigue plateaus or gets worse instead, we look harder at it. Fair?
PTFair. Thanks, Doc. This was less depressing than I budgeted for.
DRThat's the review headline I want. Sit tight, the nurse is coming with your vaccine, and the front desk will book your follow-up.
NURSEKnock knock — flu vaccine delivery. Which arm are we sacrificing?
PTLeft. The right one is my resume-clicking arm.
NURSELeft it is. Little pinch... aaand done. Keep the arm moving today; it might complain a bit tomorrow.
PTAfter a ventilator, I think I can survive a sore shoulder.
NURSEThat's the spirit. You're all set — checkout is around the corner to your right.
PTThank you both. Time for grandpa lap number two — the parking lot.