Annual physical — prediabetes and psychosocial screening
Nigel Giovanni Ankunding · 52y · male · 2019-04-22
General examination of patient (procedure)
Chart background
Active conditions
- Chronic sinusitis (disorder)
- Educated to high school level (finding)
- Prediabetes (finding)
- Has a criminal record (finding)
- Medication review due (situation)
- Social isolation (finding)
- Stress (finding)
Active medications
None recorded
After-visit summary
Visit summary What we discussed • Prediabetes • Stress • Social isolation • Depression and substance use screening • Medication review due • Chronic sinusitis • Health maintenance Next steps • Lifestyle counseling provided: 20 minutes of pre-shift exercise 4-5 days weekly; replace late-night fast food with packed meals. • Repeat HbA1c at the next annual visit, sooner if symptoms develop. • Discussed exercise and stress-management strategies as first-line. • Return sooner if worry becomes uncontrollable or disrupts sleep or function. • Patient plans to join a Saturday bowling league; will revisit at follow-up. • No intervention indicated; continue current low-level weekend alcohol use. • Rescreen annually. • Medication reconciliation completed; regimen confirmed as sodium fluoride oral gel nightly plus occasional OTC acetaminophen.
deterministic_extractive_v1 · not_clinically_reviewed
Clinical note
**Subjective:** Nigel Ankunding is a 52-year-old man presenting for a general adult examination, his first complete physical in roughly two years. He feels well overall with no acute complaints. His main chronic issue is longstanding sinus pressure across the forehead with morning congestion and intermittent headaches rated up to 4/10, unchanged in character for years; he denies fever, purulent drainage, dental pain, or any episode suggesting acute infection this season. He describes persistent work-related stress in his role as a second-shift logistics coordinator — difficulty switching off after shifts, muscle tension, and jaw clenching — without panic symptoms. He also endorses social isolation: he lives with his brother but their schedules rarely overlap, he gave up his bowling league about a year ago, and he acknowledges loneliness while denying depressed mood or anhedonia. Sleep averages six hours; appetite is intact, with frequent late-night fast food on shift and little structured exercise. He is concerned about diabetes given a strong family history (mother with amputation). ROS is otherwise negative: no chest pain, palpitations, dyspnea, polyuria, polydipsia, unintentional weight change, or GI symptoms. He has never smoked; alcohol is two to three beers on weekend nights; no other substance use. Active problems include chronic sinusitis and prediabetes. Medication review was due: his only regular agent is sodium fluoride 0.0272 mg/mg oral gel, with occasional acetaminophen for sinus headache. No known allergies. **Objective:** Vitals: BP 111/71 mmHg, HR 88/min, RR 13/min, height 179.6 cm, weight 90.4 kg, BMI 28.03 kg/m2, reported pain 4/10. Exam: well-appearing man in no distress; mild tenderness over the frontal sinuses; oropharynx clear; heart regular without murmur; lungs clear; abdomen soft and nontender; no edema. Labs: HbA1c 5.83%; glucose 81.1 mg/dL; BUN 19.99 mg/dL; creatinine 1.1 mg/dL; calcium 9.31 mg/dL; sodium 141.35, potassium 4.84, chloride 105.25, CO2 22.71 mmol/L. CBC: WBC 8.78, hemoglobin 13.04 g/dL, hematocrit 44.62%, MCV 86.09 fL, platelets 340.2. Screening scores: PHQ-2 total 1; GAD-7 total 4; AUDIT-C total 3. **Assessment and Plan:** ### Prediabetes HbA1c 5.83% with a normal glucose of 81.1 mg/dL — just above the prediabetes threshold and essentially stable, without progression to diabetes. - Lifestyle counseling provided: 20 minutes of pre-shift exercise 4-5 days weekly; replace late-night fast food with packed meals. - Repeat HbA1c at the next annual visit, sooner if symptoms develop. ### Stress Persistent occupational stress with tension symptoms; formal assessment of anxiety today reassuring, GAD-7 of 4 in the minimal-to-mild range. - Discussed exercise and stress-management strategies as first-line. - Return sooner if worry becomes uncontrollable or disrupts sleep or function. ### Social isolation Identified during assessment of health and social care needs; patient is receptive to re-engagement. - Patient plans to join a Saturday bowling league; will revisit at follow-up. ### Depression and substance use screening Depression screening negative (PHQ-2 total 1). Assessment of substance use and AUDIT-C (total 3) below the threshold of concern for his age and sex; lifelong never-smoker. - No intervention indicated; continue current low-level weekend alcohol use. - Rescreen annually. ### Medication review due - Medication reconciliation completed; regimen confirmed as sodium fluoride oral gel nightly plus occasional OTC acetaminophen. ### Chronic sinusitis Stable baseline pressure symptoms with mild frontal tenderness and no evidence of acute bacterial infection today. - Continue saline rinses as needed; return for fever, purulent drainage, or refractory pain. ### Health maintenance - Influenza vaccine (split virus, trivalent, preservative-free) administered today as end-of-season catch-up. - Basic metabolic panel and CBC completed and reviewed with the patient — no abnormalities requiring action.
FHIR resources at this visit
Transcript
DRGood morning, Mr. Ankunding — Nigel, right? Come on in and grab a seat. It has been almost two years since we did a full physical on you.
PTYeah, I know. Work kept eating my weekends, and honestly I feel fine, so it kept sliding down the list.
DRWell, I am glad you made it in. Anything bothering you today, or is this mostly a tune-up?
PTMostly a tune-up. The only thing, really, is my sinuses. Same as always. Pressure behind my forehead, stuffy in the mornings. Some days it works itself into a headache — maybe a four out of ten at its worst. It has been like that for years.
DRThat fits with the chronic sinusitis we have on your chart. Any fever, colored drainage, tooth pain, anything that felt like a full-blown infection recently?
PTNo, nothing like that. Just the pressure. Annoying more than anything.
DROkay. And the rest of you — energy, sleep, appetite?
PTEnergy is okay. Sleep is... eh. I am a logistics coordinator on second shift, so my hours are backwards from everybody else. I get maybe six hours. Appetite is fine. Too fine, probably.
DRWe will talk numbers in a minute — your weight is actually not bad. Before that, catch me up on life. Last time you were here you had just started that job, I think.
PTStill there. Three years in June. It is steady, which I do not take for granted. With my record, it took a long time to find a place that would keep me on, so I do not rock the boat. But it is a lot of pressure. If a truck is late, it is my phone that rings. Lately I feel wound up all the time.
DRWound up how — racing thoughts, trouble switching off, irritable?
PTTrouble switching off, mostly. I get home at midnight and my brain keeps running tomorrow's schedule. I would not say I am anxious, exactly. Just tense. Tight shoulders, clenching my jaw at my desk. That kind of thing.
DRThat is useful to know. And who is at home? Anybody around to talk it out with?
PTMy brother Marcus stays with me. He works days, so mostly we wave at each other in the hallway. Other than him, honestly, not much. I used to bowl in a Sunday league, but I dropped it when I moved to second shift. It has been about a year since I did anything social.
DRDo you miss it?
PTYeah. I am not going to pretend it does not get lonely some nights. But I am not sitting around crying about it either. It is what it is.
DRI hear you. I ask because loneliness works on the body the same way stress does — blood pressure, sugar, sleep, all of it. So I take it as seriously as any lab. Speaking of which — the forms you filled out up front. The mood questions came back very low, a one, so depression is not showing its hand. Does that feel right? Still enjoying things?
PTMostly, yeah. I am flat sometimes, but not down. I still watch my games. I cook on my days off. Sunday I made a gumbo that would make you weep.
DRNow I am hungry, thanks. The worry questionnaire put you at a four, which is the mild end — that matches the wound-up-but-managing picture you are describing. And the alcohol questions — you put down a couple of beers on weekends?
PTSaturday nights. Two, maybe three if the game goes long. Never before a shift.
DRYour score there was a three, which for a man your age is under the level where we worry. Just keep it where it is. Any tobacco, vaping, marijuana, anything else?
PTNever smoked in my life. Nothing else either. I saw enough of that go wrong around me growing up.
DRUnderstood. Let me examine you, then we will go over the labs from your draw last week. Deep breath... again... good. Press here — tender?
PTA little, yeah. Right over the eyebrows.
DRThat is the sinus tenderness, matches your story. Everything else checks out. So, numbers. Blood pressure today is 111 over 71 — excellent. Heart rate 88, breathing 13 a minute. You are 179.6 centimeters, 90.4 kilos, which puts the BMI at 28.03 — carrying a little extra, but stable.
PTAnd the sugar? That is the one my mother had. She lost a toe to it. I think about that.
DRI was getting there, and it is decent news. You remember we flagged you as prediabetic. Your A1c — the three-month sugar average — came back at 5.83 percent. Prediabetes starts at 5.7, so you are just over the line and holding steady, not climbing. Your glucose was 81.1, completely normal. Kidneys look good — creatinine 1.1, urea nitrogen about 19.99. Electrolytes all in range. Blood count is fine — hemoglobin 13.04, platelets 340. Nothing scary anywhere.
PTSo I am not diabetic.
DRYou are not. You are in the gray zone, same as before, and the job is keeping you from crossing over. Realistically — on your schedule, what movement could you actually stick with?
PTThere is a little gym at the warehouse nobody uses. I could do twenty minutes before shift. Treadmill, maybe some weights.
DRTwenty minutes before shift, four or five days a week — if you actually do it, that is the single best medicine I can offer for the sugar, the weight, and the stress, all in one. Second thing: the midnight meals. What does dinner look like at eleven p.m.?
PTDrive-through, more than I want to admit. It is what is open.
DRFair. Pack something instead — the man who makes weeping-grade gumbo can pack a cooler. Even a sandwich and fruit beats the drive-through three different ways.
PTMy brother packs a cooler every day. He will gloat, but fine. I can do that.
DRGood. Now, medications. My list shows basically nothing regular — just the prescription fluoride gel from your dentist. Still right? No supplements, nothing over the counter you take routinely?
PTThat is it. The gel at night, and a Tylenol maybe once a month for the sinus headache. That is the whole list.
DRPerfect — that settles the medication review, all reconciled and up to date. One piece of housekeeping: you never got a flu shot this past season. The season is winding down, but you work around a lot of people, and I have the vaccine here. I would rather catch you now than miss you again in the fall.
PTGo ahead. I am not precious about needles.
DRGreat — the nurse will put it in your left arm before you go. Last thing, and it is the one I care most about. The stress and the isolation — I am writing both down as real problems today, the same way I would a blood pressure. Not because you are doing badly, but because over the next ten years they are the things most likely to wear you down. Would you consider picking one social thing back up?
PTThere is a Saturday morning league, actually. Different crowd than the old one. I have thought about it a couple times.
DRThen that is your prescription. Saturday league, twenty minutes on the treadmill, pack the cooler. And if the tension ever tips into something heavier — mood dropping, no joy in anything, worry you cannot shut off — you call me. There are good options and we would not wait a year.
PTThat is fair. And the sinuses — anything new for those?
DRKeep up saline rinses if they help, and come in if you get fever, bad drainage, or pain that will not quit — that is when it needs more than rinses. Otherwise we recheck everything, including the A1c, in a year. Sound like a plan?
PTSounds like a plan. I appreciate you not lecturing me, Doc.
DRYour numbers did the talking for you. The nurse will be right in with that flu shot. Take care of yourself, Nigel — and save me some gumbo next spring.
PTNo promises. Gumbo goes fast. Thanks, Doc.