Annual wellness examination — preventive screening and health maintenance
Corinne Charlesetta Crooks · 46y · female · 2017-01-01
General examination of patient (procedure)
Chart background
Active conditions
- Risk activity involvement (finding)
- Received higher education (finding)
- Chronic sinusitis (disorder)
- History of tubal ligation (situation)
- Body mass index 30+ - obesity (finding)
- Medication review due (situation)
- Not in labor force (finding)
Active medications
None recorded
After-visit summary
Visit summary What we discussed • Health maintenance and preventive screening • Not in labor force — recent work transition • Chronic sinusitis • Weight and lifestyle • Medication review due Next steps • Influenza vaccine (split virus, trivalent, PF) administered today given missed fall dosing. • Continue routine age-appropriate screening; return in one year. • Encouraged continued daily walking and social engagement; will rescreen mood at future visits. • Daily saline rinses through the winter; humidifier at night. • Return precautions: fever, tooth pain, or a week of steady worsening. • Positive reinforcement given; continue current activity and diet pattern. • Patient to bring all medication bottles, including leftover medications at home, to the next visit for full reconciliation.
deterministic_extractive_v1 · not_clinically_reviewed
Clinical note
**Subjective:** Corinne Crooks is a 47-year-old woman presenting for a general physical examination and annual preventive care. She left her office job of nineteen years in October and is newly out of the labor force; she describes the adjustment as mixed but overall positive, with improved sleep, energy, and daily structure built around a 45-minute daily walk and new social activities. She lives with her husband in a two-person household with reported annual income of about $53,274 and stable insurance through his employment; she denies material hardship. Her chronic sinusitis is behaving in its usual winter pattern — bilateral facial pressure, morning congestion, and nighttime post-nasal drip, currently a minor nuisance (pain 1/10) — without fever, severe headache, tooth pain, or purulent discharge; she uses saline rinses intermittently. She reports exertional tolerance has improved on her walks. She is an ex-smoker (brief teenage use, quit decades ago) with no relapse, drinks at most one glass of wine weekly, and denies other substance use. She denies depressed mood or anhedonia, endorsing only brief, proportionate financial worry after leaving work. ROS otherwise negative: no chest pain, dyspnea, palpitations, weight loss, fevers, GI or GU symptoms, or abnormal bleeding. **Objective:** Vitals: BP 102/71 mmHg, HR 70/min, RR 14/min, height 170.6 cm, weight 81.8 kg, BMI 28.1 kg/m2, reported pain 1/10. General: well-appearing, animated, no distress. HEENT: mild maxillary tenderness with congested nasal mucosa, consistent with chronic sinusitis; no purulence. Cardiovascular: regular rate and rhythm. Lungs: clear. Abdomen: soft, nontender. Labs: total cholesterol 148.41 mg/dL, triglycerides 126.54 mg/dL, direct LDL 64.34 mg/dL, HDL 58.76 mg/dL. CBC: WBC 7.41 10*3/uL, hemoglobin 12.31 g/dL, hematocrit 43.09%, platelets 436.75 10*3/uL. Screening scores: PHQ-2 total 0; GAD-7 total 1; AUDIT-C total 1. Tobacco status: ex-smoker. PRAPARE: household of 2, income $53,274/year. **Assessment and Plan:** ### Health maintenance and preventive screening Annual examination with reassuring vitals, lipid panel, and CBC; depression screening (performed twice, PHQ-2 0), anxiety assessment (GAD-7 1), substance use assessment, and AUDIT-C (1) are all negative or minimal. - Influenza vaccine (split virus, trivalent, PF) administered today given missed fall dosing. - Continue routine age-appropriate screening; return in one year. ### Not in labor force — recent work transition Newly documented; adjustment is going well with adequate finances and growing social supports; health and social care needs assessment identified no unmet needs. - Encouraged continued daily walking and social engagement; will rescreen mood at future visits. ### Chronic sinusitis Typical winter exacerbation pattern without features of acute bacterial infection today. - Daily saline rinses through the winter; humidifier at night. - Return precautions: fever, tooth pain, or a week of steady worsening. ### Weight and lifestyle BMI today 28.1 kg/m2, improved from the prior obesity-range documentation on her problem list through daily walking and routine change. - Positive reinforcement given; continue current activity and diet pattern. ### Medication review due Flagged as due at this visit. - Patient to bring all medication bottles, including leftover medications at home, to the next visit for full reconciliation.
FHIR resources at this visit
Transcript
DRCorinne Crooks — you win the prize for my very first patient of the year. January first, eight in the morning. That is commitment.
PTWhen they offered me a New Year's Day slot I laughed, and then I thought, you know what, everyone else will cancel and I will get the doctor all to myself. And here we are.
DRStrategy validated. So it has been a while — how has the year treated you? Big picture first.
PTBig picture? Honestly, the biggest thing is that I stopped working in October. Left my office job after nineteen years. So this is my first physical as a lady of leisure, which is a phrase my husband uses to annoy me.
DRIs it leisure? How is it actually sitting with you?
PTMixed, truthfully. The job had gotten miserable — the commute, the open office, a manager half my age with twice my opinions. So the leaving part was right. But I will not pretend the first month was not strange. The house is very quiet at ten in the morning. It is just the two of us at home, and he still works.
DRWhat filled the space?
PTWalking, weirdly. I started taking these long walks just to have somewhere to be at nine o'clock. Now it is every day, forty-five minutes, rain or not. And my sister-in-law dragged me into her book club, which is really a wine club with homework, but I mostly skip the wine part.
DRI want to come back to both of those, because they show up in your numbers today — in a good way. But first, how is the body? Any complaints you have been sitting on?
PTNothing dramatic. The sinuses, as always. Every winter it is the same story — pressure across here, stuffed up in the mornings, that post-nasal drip thing at night. It has been my companion for years, you know this. Right now it is grumbling, not screaming. Maybe a one out of ten nuisance-wise today.
DRAny fevers with it lately, bad headaches, tooth pain, anything thicker or more colorful than usual coming out?
PTNo, none of that. Just the usual congestion and pressure. I do the saline rinses when I remember, which is — sometimes.
DRSometimes is a start; daily is better in winter. Anything else? Chest pain, shortness of breath on your walks, palpitations?
PTNo, and honestly the walks have gotten easier, not harder. I used to puff on the hill by the reservoir and now I do not.
DRSleep, appetite, energy?
PTSleep is better since I stopped working, no alarm clock. Appetite normal. Energy honestly the best in years.
DRBowels, bladder, any bleeding anywhere it should not be?
PTAll boring, thank goodness.
DRBoring is my favorite review of systems. Now, since you left work — and I have to write that down officially, that you are out of the labor force now — I want to check the practical side. Money-wise, insurance-wise, is the household okay? We ask everyone.
PTWe are fine, truly. His job carries the insurance now, and between his salary and my little bit of consulting we brought in around fifty-three thousand last year. Two of us, paid-off car, we are not extravagant people. The math works.
DRGood. And the emotional side — I have a couple of standard screening questions, everybody gets them. Over the last two weeks, have you felt down, depressed, or hopeless?
PTNo. Restless in October, but not down.
DRLittle interest or pleasure in doing things?
PTThe opposite, I have hobbies now. I am insufferable about it.
DRFeeling nervous, anxious, on edge? Worrying you cannot switch off?
PTMmm — a flicker, when I think about whether leaving was financially wise. A couple times a month, maybe. It passes when I do the actual math.
DRThat sounds proportionate to a real life change, and your questionnaire scores agree — essentially nothing on the depression screen, one point on the anxiety scale. I asked the depression questions twice today in different forms, by the way, that is deliberate, not me forgetting.
PTI did wonder if you were testing whether I was paying attention.
DRBoth of us passed. Alcohol — the wine club with homework. How much in an average week?
PTOne glass, most weeks. Sometimes none. I was never much of a drinker, and it gives me a headache now anyway.
DRThat matches your score there too — nothing concerning. And you are still an ex-smoker, no backsliding? You quit as a teenager if I remember the chart.
PTDecades ago, barely counts as a habit — it was a stupid teenage year of it. Never since.
DRIt still goes in the chart, and it still counts in your favor. Any other substances, sleeping pills, anything recreational?
PTNo. My vice is the book club snacks.
DRThen let us examine you and go over the labs from your draw last week. Blood pressure today is one-oh-two over seventy-one, pulse seventy, breathing fourteen. Weight eighty-one point eight kilos at one meter seventy point six — your body mass index works out to twenty-eight point one.
PTWhich is down! I know it is down. The chart had me in the obese range last time, which I hated seeing.
DRIt was on your problem list, yes — and this is a genuine, measurable improvement, and you did it with walking and a quieter life, which is the sustainable way. I want to acknowledge that properly: well done.
PTThank you. The walks are non-negotiable now. Even my husband comes on Sundays.
DRKeep the Sunday recruit. Exam-wise: heart regular, lungs clear, belly soft. Sinuses — a little tenderness over the cheeks and your nose is congested inside, which fits the chronic sinusitis doing its winter grumble. Nothing that looks like an active bacterial infection today, so no antibiotics — saline rinses daily, humidifier at night, and you call me if you get fever, tooth pain, or a week of steady worsening.
PTDeal. And the blood work?
DRGenuinely lovely. Total cholesterol one forty-eight. The LDL — the artery-clogging one — is sixty-four, which is excellent. HDL, the protective one, fifty-nine. Triglycerides one twenty-seven, fine. Blood count: hemoglobin twelve point three, white cells normal, platelets at the higher end of acceptable but nothing I am worried about in context. No anemia, no red flags.
PTAll those walks paying rent.
DRThey are. Two pieces of housekeeping. One — the chart says you are due for a proper medication review. Today I mostly need to flag it: gather every bottle in the house, including the leftover antibiotics I suspect are in a drawer, and bring the whole bag to your next visit so we reconcile it properly.
PTThere is definitely a drawer. I will bring the drawer.
DRBring the drawer. Two — flu shot. You missed the fall window, but flu season runs well into spring, so getting it today still protects you. Can we do it now?
PTGo ahead. Left arm — I sleep on the right, and I have big plans for sleeping this month.
DRA woman with priorities. So, the year-one-of-leisure plan: keep the daily walks, saline rinses every morning while it is cold, one glass of wine or fewer stays fine, bring the medication drawer next visit, and the flu shot happens before you leave. Screening-wise you are up to date, and everything today says you are healthier than you were a year ago.
PTThat is the nicest report card I have gotten since grade school. Same time next year?
DRSame time next year — though maybe not January first at eight.
PTNo promises. The empty waiting room is addictive.
DRHappy New Year, Corinne. Well done on all of it.
PTHappy New Year, doctor. Thank you.