Annual physical — preventive screening and migraine check-in
Ali Jerry Kuhic · 31y · male · 2022-08-05
General examination of patient (procedure)
Chart background
Active conditions
- Risk activity involvement (finding)
- Received higher education (finding)
- Transport problem (finding)
- Lack of access to transportation (finding)
- Stress (finding)
- Chronic intractable migraine without aura (disorder)
- Social isolation (finding)
- Gingivitis (disorder)
Active medications
None recorded
After-visit summary
Visit summary What we discussed • Gingivitis • Chronic intractable migraine without aura • Social isolation and stress • Transportation insecurity • Preventive health and screening Next steps • Patient referral for dental care placed (sliding-scale clinic). • Daily flossing and twice-daily brushing reviewed. • Medication reconciliation completed and chart list updated. • Keep a simple headache log; return precautions reviewed for any change in pattern or new neurologic symptoms. • Assessment of health and social care needs completed (PRAPARE). • Care coordinator outreach this week; encouraged trial of community men's group. • Enrollment in medical ride-service program via care coordination, including dental visits. • Lifestyle counseling on diet and regular aerobic activity; repeat lipid panel to follow the trend.
deterministic_extractive_v1 · not_clinically_reviewed
Clinical note
**Subjective:** Ali Kuhic is a 31-year-old man presenting for a general physical examination, his first comprehensive visit in approximately two years. He reports feeling generally well but persistently tired, with ongoing stress driven by reduced work hours and finances; he manages the bills for a seven-person household with a reported annual family income of about $26,021. He describes unreliable access to transportation as a recurring barrier to care — he has no working household vehicle and arrived today only after his usual bus failed to run. He also describes a gradual loss of social connection since college, with no regular confidant outside the household; he denies hopelessness or persistent depressed mood, noting only occasional transient flatness in the evenings. His chronic intractable migraine without aura continues at roughly two significant attacks per week: right retro-orbital pain that builds without aura, with photophobia and occasional nausea, relieved by sleep in a dark room. The pattern is unchanged, with no new neurologic features; today he rates pain 2/10. He reports gum bleeding with brushing for months and has not seen a dentist in years. He continues recreational bike-ramp riding (risk activity involvement) and uses a helmet. He has never smoked, drinks about one beer monthly, and denies drug use. ROS otherwise negative: no fever, chills, chest pain, palpitations, dyspnea, weight change, vision change, focal weakness, or urinary or bowel complaints. **Objective:** Vitals: BP 98/83 mmHg, HR 93/min, RR 14/min, height 176.3 cm, weight 78.7 kg, BMI 25.32 kg/m2, reported pain 2/10. General: well-appearing, no acute distress. HEENT: gingival margins erythematous and edematous with contact bleeding, consistent with gingivitis; dentition grossly intact. Cardiovascular: regular rhythm, no murmur. Lungs: clear bilaterally. Abdomen: soft, nontender. Neurologic: grossly nonfocal. Labs (lipid panel with direct LDL): total cholesterol 198.2 mg/dL, triglycerides 138.79 mg/dL, direct LDL 137.19 mg/dL, HDL 33.25 mg/dL. Screening instruments: HARK total 0; DAST-10 total 0. Tobacco status: never smoked. PRAPARE: household of 7; family income $26,021/year. **Assessment and Plan:** ### Gingivitis Gingival inflammation with easy bleeding on exam; years since last dental care, with cost and transportation as barriers. - Patient referral for dental care placed (sliding-scale clinic). - Daily flossing and twice-daily brushing reviewed. ### Chronic intractable migraine without aura Stable long-standing pattern, about two attacks weekly, no red-flag features; pain 2/10 today. - Medication reconciliation completed and chart list updated. - Keep a simple headache log; return precautions reviewed for any change in pattern or new neurologic symptoms. ### Social isolation and stress Newly documented social isolation; significant financial stress and short sleep, without features of a depressive disorder today. - Assessment of health and social care needs completed (PRAPARE). - Care coordinator outreach this week; encouraged trial of community men's group. ### Transportation insecurity Transport problem and lack of access to transportation continue to interfere with appointments. - Enrollment in medical ride-service program via care coordination, including dental visits. ### Preventive health and screening Lipid panel shows LDL 137.19 mg/dL and HDL 33.25 mg/dL; domestic-abuse screening (HARK 0), substance use assessment, and drug-abuse screening (DAST-10 0) were all reassuring; never-smoker. - Lifestyle counseling on diet and regular aerobic activity; repeat lipid panel to follow the trend. - Influenza (split virus, trivalent, PF) and Td booster administered today. - Helmet and protective-gear counseling for recreational ramp riding. - Return visit in one year, or sooner as needed.
FHIR resources at this visit
Transcript
DRGood morning — Ali, right? Come on in, grab a seat. How was the trip over?
PTMorning. It was an adventure. The bus I usually take never showed, so I walked the last mile and a half. That is why I am sweaty, by the way. Not nerves.
DRNoted, no nerves. I am glad you made it. It has been about two years since we did a full check-up on you, I think.
PTYeah. I kept meaning to come in, but between work and everything at home, and honestly just getting here, it kept sliding.
DRGetting here being the bus situation?
PTPretty much. We do not have a car right now. My cousin has one, but there are seven of us in the house and one car that runs sometimes, so. The bus is the plan, and the plan is unreliable.
DRThat is genuinely useful for me to know, and I want to circle back to it before you leave, because there may be some help we can set up. First, big picture — how have you been feeling?
PTMostly okay. Tired a lot. The headaches are still around. Stress is... yeah. Stress is there.
DRLet us take those one at a time. Tell me about the headaches — the chronic migraines have been with you a few years now.
PTSince my mid-twenties. No warning lights or anything before they start, no aura, they just build behind my right eye and then I am done for the day. Lately maybe two bad ones a week. Some weeks are better.
DRWhat does a bad one look like for you?
PTDark room, no sound. If it hits at work I push through and regret it. Light makes it worse, and sometimes I get queasy with it. Sleep is the only thing that really resets it.
DRAny change in the pattern recently — worse than before, new symptoms, weakness on one side, vision changes, anything like that?
PTNo, same old enemy. Today is actually a decent day. Like a two out of ten. Background noise.
DRGood. While you are here I want to do a proper medication reconciliation — walk through everything you actually take, not just what the chart says. Run me through it?
PTSure. Honestly it is a short list. The stuff I keep for when a headache gets really bad, and that is about it. I am not a big pill person.
DROkay, we will go line by line on the screen and update the chart together, because I want the list to be accurate. Anything over the counter? Vitamins, supplements, anything you borrow from anybody at home?
PTNo. Coffee, if that counts.
DRCoffee counts as a food group at this point. Now — you said stress. What is driving it?
PTMoney, mostly. My hours got cut in the spring. With seven people in the house everything is loud and busy, and I am the one who handles the bills. Last year we brought in about twenty-six thousand all together, and it does not stretch.
DRThat is a lot to carry. How are you sleeping?
PTFive, six hours. I fall asleep fine, my brain just clocks in early.
DRAnd who do you have — people you can actually talk to, not just live with?
PTHm. That is the thing. The house is full, but they are family, you know? My friends kind of scattered after college. There is not really anyone I just hang out with anymore. I did not notice it happening. It just happened.
DRI hear that more often than you would think, and it matters for your health as much as the lab work does. I am going to write it down as something we actively work on, not just a fact about you. Do you get low moods with it? Losing interest in things, feeling hopeless?
PTNot hopeless. More like flat, some evenings. It lifts.
DROkay. I am also going to run through some standard screening questions we do with everyone at these visits. Some are personal, and you can decline any of them. First set is about safety at home. Within the last year, has anyone humiliated you, made you afraid, forced anything on you physically or sexually, or hit or kicked you?
PTNo. None of that. The house is chaotic, not dangerous.
DRGood. Next set is substances. Alcohol — how often?
PTA beer at a barbecue, maybe. Once a month?
DRAny drug use — cannabis, pills that are not yours, anything recreational?
PTNo. I watched what that did to a guy I grew up with. Not for me.
DRI will still have you fill out the short written questionnaire, it is the same ten questions for everybody. And you have never smoked, correct?
PTNever. Mom was strict about it — the house was always smoke-free, and I just kept the rule.
DRGreat. Now, the risky stuff you do for fun. You mentioned bike jumps last time.
PTHa. Still guilty. My nephew and I built a bigger ramp this summer. I wear the helmet, before you say it.
DRI was absolutely going to say it. Helmet every time, wrist guards if you can, and no new ramps taller than you. Deal?
PTDeal-ish.
DRI will take it. All right, hop up here and let me examine you. Your numbers today look reasonable — blood pressure ninety-eight over eighty-three, heart rate ninety-three, breathing fourteen a minute. Height one seventy-six, weight seventy-eight point seven, which puts your body mass index right around twenty-five.
PTNinety-three heart rate — is that from the walk?
DRCould be the surprise cardio plus the coffee. Rhythm is regular, no murmurs. Lungs are clear. Belly is soft, no tenderness. Open your mouth for me... okay. Your gums — do they bleed when you brush?
PTYeah, a little pink in the sink most mornings. I figured I was brushing too hard.
DRThey are inflamed along the edges — that is gingivitis. Early gum disease. The fix is very doable: a proper dental cleaning and better daily care, flossing especially. When did you last see a dentist?
PTHonestly? Years. Dental was never covered, and — the bus thing again.
DRUnderstood. I am putting in a referral to the dental clinic that works on a sliding scale. And this connects to the transportation piece — our care coordinator can enroll you in the medical ride service, so the bus does not get a veto over your health care. It covers dental visits too.
PTA ride service? That would honestly change a lot.
DRIt is exactly why we ask the needs questions. Now, your lab work from the draw this morning. Total cholesterol is one ninety-eight. Triglycerides one thirty-nine — fine. The LDL, the buildup kind, is one thirty-seven, a bit higher than I want. And your HDL, the protective kind, is thirty-three, lower than I want.
PTIs that medicine territory?
DRNot today. At thirty-one, with everything else looking good, this is a food-and-movement conversation. More beans, fish, oats, fewer fried things — and the bike counts as cardio when it is not airborne. We will recheck it and watch the trend.
PTOkay. I can work with that. The fried stuff will hurt, though.
DRI am not taking it away, I am demoting it. Last thing — vaccines. You are due for a flu shot, and your tetanus booster is overdue, which matters for a man who builds ramps out of scrap wood. Can we do both today?
PTSure. Left arm for both. I sleep on the right.
DRDone. The nurse will give those before you go. So, the recap. Gums — dental referral, floss daily, the ride service will get you there. Cholesterol — diet and movement, recheck later. Migraines — stable pattern, keep a simple log of the bad days if you can. Stress and the isolation piece — the coordinator will call you this week, and there is a men's group at the community center on Thursday evenings I want you to try. Once.
PTOne time. If it is weird, I am out.
DRIf it is weird, you tell me and we find a different one. Questions for me?
PTNo... actually, yes. The tetanus shot — sore arm?
DRFor a day or two. Ramp construction not recommended tomorrow. Anything else on your mind?
PTNo, that is it. Thanks, doc. This was less painful than the bus.
DRHigh praise. The front desk will print your dental referral and the lab slip for the recheck, and I would like to see you back sooner than two years, please.
PTFair. See you, doc.