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D2N001

[doctor] hi , martha . how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ? [patient] i'm doing well . i've been traveling a lot recently since things have , have gotten a bit lighter . and i got my , my vaccine , so i feel safer about traveling . i've been doing a lot of hiking . uh , went to washington last weekend to hike in northern cascades, like around the mount baker area . [doctor] nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person . [patient] yes , fall foliage is the best . [doctor] yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ? [patient] i've been doing well with that . i resisted , as much , as i could , from the tater tots , you know , the soft pretzels , the salty foods that i , i love to eat . and i've been doing a really good job . [doctor] okay , all right . well , i'm glad to hear that . and you're taking your medication ? [patient] yes . [doctor] okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ? [patient] no , not that i've noticed . [doctor] okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or- [patient] yeah , it's been helping a lot . i've been going every week , um , for the past year since my last annual exam . and that's been really helpful for me . [doctor] okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ? [patient] no , nothing like that . [doctor] okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ? [patient] i'm still forgetting to take my blood pressure medication . and i've noticed when work gets more stressful , my blood pressure goes up . [doctor] okay . and , and so how has work going for you ? [patient] it's been okay . it's been a lot of long hours , late nights . a lot of , um , you know , fiscal year end data that i've been having to pull . so , a lot of responsibility , which is good . but with the responsibility comes the stress . [doctor] yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ? [patient] no , nothing like that . [doctor] no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , dragon , show me the blood pressure readings . hey , dragon , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ? [patient] okay . [doctor] so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ? [patient] okay . [doctor] okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ? [patient] okay . [doctor] let's go ahead , i wan na look at some of your results , okay ? hey , dragon , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ? [doctor] um , hey , dragon , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ? [patient] okay . [doctor] um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ? [patient] okay . [doctor] i also wan na repeat another echocardiogram , okay ? [patient] all right . [doctor] hey , dragon , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently . [patient] no , i feel the same way . [doctor] okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ? [patient] okay . [doctor] do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ? [patient] okay . [doctor] okay . do you have any questions ? [patient] can i take all my pills at the same time ? [doctor] yeah . [patient] 'cause i've been trying to take them at different times of the day , 'cause i did n't know if it was bad to take them all at once or i should separate them . i do n't know . [doctor] yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm- [patient] okay . [doctor] . some time during the day to take them , okay ? [patient] that might help me remember better . [doctor] all right . that sounds good . all right , well , it's good to see you . [patient] good seeing you too . [doctor] hey , dragon , finalize the note .

CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Martha Collins is a 50-year-old female with a past medical history significant for congestive heart failure, depression, and hypertension who presents for her annual exam. It has been a year since I last saw the patient. The patient has been traveling a lot recently since things have gotten a bit better. She reports that she got her COVID-19 vaccine so she feels safer about traveling. She has been doing a lot of hiking. She reports that she is staying active. She has continued watching her diet and she is doing well with that. The patient states that she is avoiding salty foods that she likes to eat. She has continued utilizing her medications. The patient denies any chest pain, shortness of breath, or swelling in her legs. Regarding her depression, she reports that she has been going to therapy every week for the past year. This has been really helpful for her. She denies suicidal or homicidal ideation. The patient reports that she is still forgetting to take her blood pressure medication. She has noticed that when work gets more stressful, her blood pressure goes up. She reports that work has been going okay, but it has been a lot of long hours lately. She endorses some nasal congestion from some of the fall allergies. She denies any other symptoms of nausea, vomiting, abdominal pain. REVIEW OF SYSTEMS • Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies. • Cardiovascular: Denies chest pain or dyspnea on exertion. • Respiratory: Denies shortness of breath. • Gastrointestinal: Denies abdominal pain, nausea, or vomiting. • Psychiatric: Endorses depression. Denies suicidal or homicidal ideations. PHYSICAL EXAMINATION • Cardiovascular: Grade 3/6 systolic ejection murmur. 1+ pitting edema of the bilateral lower extremities. VITALS REVIEWED • Blood Pressure: Elevated. RESULTS Echocardiogram demonstrates decreased ejection fraction of 45%. Mitral regurgitation is present. Lipid panel: Elevated cholesterol. ASSESSMENT AND PLAN Martha Collins is a 50-year-old female with a past medical history significant for congestive heart failure, depression, and hypertension who presents for her annual exam. Congestive heart failure. • Medical Reasoning: She has been compliant with her medication and dietary modifications. Her previous year's echocardiogram demonstrated a reduced ejection fraction of 45%, as well as some mitral regurgitation. Her cholesterol levels were slightly elevated on her lipid panel from last year. • Additional Testing: We will order a repeat echocardiogram. We will also repeat a lipid panel this year. • Medical Treatment: She will continue with her current medications. We will increase her lisinopril to 40 mg daily and initiate Lasix 20 mg daily. • Patient Education and Counseling: I encouraged her to continue with dietary modifications. Depression. • Medical Reasoning: She is doing well with weekly therapy. Hypertension. • Medical Reasoning: She has been compliant with dietary modifications but has been inconsistent with the use of her medication. She attributes elevations in her blood pressure to increased stress. • Medical Treatment: We will increase her lisinopril to 40 mg daily as noted above. • Patient Education and Counseling: I encouraged the patient to take her lisinopril as directed. I advised her to monitor her blood pressures at home for the next week and report them to me. Healthcare maintenance. • Medical Reasoning: The patient is due for her routine mammogram. • Additional Testing: We will order a mammogram and have this scheduled for her. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N002

[doctor] hi , andrew , how are you ? [patient] hi . good to see you . [doctor] it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ? [patient] uh , so , over the the weekend , we've been moving boxes up and down our basements stairs , and by the end of the day my knees were just killing me . [doctor] okay . is , is one knee worse than the other ? [patient] equally painful . [doctor] okay . [patient] both of them . [doctor] and did you , did you injure one of them ? [patient] um , uh , i've had some knee problems in the past but i think it was just the repetition and the weight of the boxes . [doctor] okay . all right . and , and what have you taken for the pain ? [patient] a little tylenol . i iced them for a bit . nothing really seemed to help , though . [doctor] okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ? [patient] uh , saturday night it actually kept me up for a bit . they were pretty sore . [doctor] mm-hmm . okay . and any other symptoms like fever or chills ? [patient] no . [doctor] joint pain ... i mean , like muscle aches ? [patient] no . [doctor] nausea , vomiting , diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys . [patient] mm-hmm . [doctor] um , how are you doing with that ? i know that you told dr. gutierrez- [patient] mm . [doctor] . a couple of weeks ago . [patient] yes . [doctor] everything's okay ? [patient] so far , so good . [doctor] all right . and you're taking your immunosuppressive medications ? [patient] yes , i am . [doctor] okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ... [patient] no , n- nothing out of the ordinary , from what they reported . [doctor] okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ? [patient] uh , yes , i am . [doctor] you're taking it regularly ? [patient] on the clock , yes . [doctor] yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ? [patient] no , nothing out of the ordinary . [doctor] okay . and just in general , you know , i know that we've kind of battled with your arthritis . [patient] mm-hmm . [doctor] you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant . [patient] sure . [doctor] so other than your knees , any other joint pain or anything like that ? [patient] every once in a while , my elbow , but nothing , nothing out of the ordinary . [doctor] okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ? [patient] no . [doctor] no headaches ? [patient] no headaches . [doctor] anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good . [patient] mm-hmm . [doctor] your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ? [patient] perfect . [doctor] all right . does that hurt ? [patient] a little bit . that's tender . [doctor] okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur- [patient] mm-hmm . [doctor] . which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ? [patient] mm-hmm . [doctor] so let's take a look at that . [patient] sure . [doctor] hey , dragon , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history . [patient] mm-hmm . [doctor] okay ? hey , dragon , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised . [patient] mm-hmm . [doctor] and it looks like your kidney function is also very good . so i'm , i'm very happy about that . [patient] yeah . [doctor] okay ? so i just wan na go over a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed . [patient] okay . [doctor] okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , dragon , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ? [patient] you got it . [doctor] for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ? [patient] sure . [doctor] hey , dragon , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ... [patient] mm-hmm . [doctor] you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ? [patient] you got it . [doctor] you have any questions ? [patient] not at this point . [doctor] okay . hey , dragon , finalize the note .

CHIEF COMPLAINT Joint pain. HISTORY OF PRESENT ILLNESS Andrew Perez is a 62-year-old male with a past medical history significant for a kidney transplant, hypothyroidism, and arthritis. He presents today with complaints of joint pain. The patient reports that over the weekend, he was moving boxes up and down the basement stairs. By the end of the day, his knees were very painful. The pain is equal in the bilateral knees. He states that he has had some knee problems in the past, but he believes that it was due to the repetition and the weight of the boxes. He states that the pain does not prevent him from doing his activities of daily living. By the end of the day on Saturday, his knee soreness interrupted his sleep. The patient has taken Tylenol and iced his knees for a short period of time, but nothing really seemed to help. The patient states that he had a kidney transplant a few years ago for some polycystic kidneys. He notes that he saw Dr. Gutierrez a couple of weeks ago, and everything was normal at that time. The patient continues to utilize his immunosuppressant medications. Regarding his hypothyroidism, the patient states that he is doing well. He has continued to utilize Synthroid regularly. In regards to his arthritis, the patient states that occasionally he has pain in his elbow, but nothing out of the ordinary. He denies any other symptoms such as fever, chills, muscle aches, nausea, vomiting, diarrhea, fatigue, and weight loss. REVIEW OF SYSTEMS • Constitutional: Denies fevers, chills, or weight loss. • Musculoskeletal: Denies muscle pain. Endorses joint pain in the bilateral knees. • Neurological: Denies headaches. PHYSICAL EXAMINATION • Cardiovascular: 2/6 systolic ejection murmur, stable. • Musculoskeletal: There is edema and erythema of the right knee with pain to palpation. Range of motion is decreased. Left knee exam is normal. RESULTS X-ray of the right knee is unremarkable. Good bony alignment. No acute fractures. Labs: Within normal limits. White blood cell count is within normal limits. Kidney function is normal. ASSESSMENT AND PLAN Andrew Perez is a 62-year-old male with a past medical history significant for a kidney transplant, hypothyroidism, and arthritis. He presents today with complaints of joint pain. Arthritis. • Medical Reasoning: The patient reports increased joint pain in his bilateral knees over the past weekend. Given that his right knee x-ray was unremarkable, I believe this is an acute exacerbation of his arthritis. • Additional Testing: We will order an autoimmune panel for further evaluation. • Medical Treatment: Initiate Ultram 50 mg every 6 hours as needed. • Patient Education and Counseling: I advised the patient to rest his knees. If his symptoms persist, we can consider further imaging and possibly a referral to physical therapy. Hypothyroidism. • Medical Reasoning: The patient is doing well on Synthroid and is asymptomatic at this time. • Additional Testing: We will order a thyroid panel. • Medical Treatment: Continue Synthroid. Status post renal transplant. • Medical Reasoning: He is doing well and has been compliant with his immunosuppressive medications. On recent labs, his white blood cell count was within a normal limits and his kidney function is stable. • Medical Treatment: Continue current regimen. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N003

[doctor] hi , john . how are you ? [patient] hey . well , relatively speaking , okay . good to see you . [doctor] good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you . [patient] okay . [doctor] so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ? [patient] uh , i'm feeling a lot of the same pain that i had when i had kidney stones about two years ago , so i'm a little concerned . [doctor] yeah . and so wh- what side of your back is it on ? [patient] uh , honestly , it shifts . it started from the right side and it kinda moved over , and now i feel it in the left side of my back . [doctor] okay . and , um , how many days has this been going on for ? [patient] the last four days . [doctor] okay . and is ... is the pain coming and going ? [patient] um , at first it was coming and going , and then for about the last 48 hours , it's been a constant , and it's ... it's been pretty bad . [doctor] okay . and what have you taken for the pain ? [patient] tylenol , but it really does n't seem to help . [doctor] yeah . okay . and do you have any blood in your urine ? [patient] um , uh , it ... i think i do . it's kind of hard to detect , but it does look a little off-color . [doctor] okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ? [patient] um , if i'm doing something i'm ... i'm , uh , like exerting myself , like climbing the three flights of stairs to my apartment or running to catch the bus , i feel a little dizzy and a little light headed , and i ... i still feel a little bit more pain in my abdomen . [doctor] okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago . [patient] i've been pretty diligent about taking the meds . i ... i wan na make sure i stay on top of that , so i've been pretty good with that . [doctor] okay , so no issues with the migraine ? [patient] none whatsoever . [doctor] okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes . [patient] yeah , i've been pretty good with the diet , but with the pain i have been having, it has been easier to call and have something delivered. so i have been ordering a lot of take-out and fast food that can be delivered to my door so i don't have to go out and up and down the steps to get it myself. but other than that , it's been pretty good . [doctor] okay . are you staying hydrated ? [patient] yes . [doctor] okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ? [patient] i have some body aches because i think i'm ... i'm favoring , um , my back when i'm walking because of the pain , like i kinda feel it in my muscles , but not out of the ordinary and not surprised 'cause i remember that from two years ago . [doctor] okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] sure . [doctor] okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that . [patient] mm-hmm . [doctor] um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ? [patient] sure . [doctor] hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one- [patient] mm-hmm . [doctor] . of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ? [patient] okay . [doctor] so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ? [patient] mm-hmm . [doctor] and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ? [patient] okay . [doctor] hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that . [patient] yes , i am . [doctor] for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ? [patient] actually , i do need a refill . [doctor] okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so . [patient] perfect . [doctor] if your symptoms worsen , just give me a call , okay ? [patient] you got it . [doctor] take care . [patient] thank you . [doctor] hey ... hey , dragon ? finalize the note .

CHIEF COMPLAINT Back pain. HISTORY OF PRESENT ILLNESS Mr. John Perry is a 61-year-old male with a past medical history significant for kidney stones, migraines, and gastroesophageal reflux, who presents with some back pain. The patient reports that he is feeling a lot of the same pain that he had when he had kidney stones about 2 years ago, so he is a little concerned. The pain started from the right side and moved over and he feels it on the left side of his back. This has been going on for the last 4 days. Initially, the pain was intermittent, but over the last 48 hours it has been constant. He has taken Tylenol, but it does not seem to help. He thinks he has hematuria, but it is hard to detect but it does look a little off color. He endorses nausea and vomiting if he exerts himself or climbs the stairs to his apartment or runs to catch the bus. He also endorses dizziness and lightheadedness with pain in his abdomen. Regarding his migraines, he has been diligent about taking the Imitrex. He denies issues with the migraines. Regarding his gastroesophageal reflux, he reports that he has been doing well with his diet, but notes lately with his pain, he has been eating more fast food and takeout since these options come with delivery. He is staying hydrated. He is taking Protonix 40 mg daily as directed. REVIEW OF SYSTEMS • Gastrointestinal: Endorses abdominal pain. Endorses nausea and vomiting with exertion. • Genitourinary: Endorses urine discoloration. • Musculoskeletal: Endorses back pain. Endorses body aches. • Neurological: Denies headaches. Endorses dizziness and lightheadedness. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds. • Gastrointestinal: Tender to palpation to the right lower quadrant. CVA tenderness on the right. VITALS REVIEWED • Blood Pressure: Elevated. RESULTS Creatinine level slightly elevated. Abdominal x-ray demonstrates possible kidney stone. ASSESSMENT AND PLAN Mr. John Perry is a 61-year-old male with a past medical history significant for kidney stones, migraines, and gastroesophageal reflux, who presents with back pain. Kidney stones. • Medical Reasoning: He is experiencing pain in his back that is similar to his previous kidney stone pain. His recent abdominal x-ray demonstrates what appears to be a recurrent kidney stone. • Additional Testing: I have ordered a CT scan of the abdomen and pelvis without contrast. • Medical Treatment: We will start him on Ultram 50 mg as needed every 6 hours for pain. • Patient Education and Counseling: I advised the patient to stay well hydrated and to strain his urine. Migraines. • Medical Reasoning: He has been compliant with Imitrex and is doing well at this time. • Medical Treatment: Continue Imitrex. Reflux. • Medical Reasoning: This is typically well-controlled with dietary modifications. • Medical Treatment: Continue with Protonix 40 mg daily. A refill was provided. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N004

[doctor] hi , james , how are you ? [patient] hey , good to see you . [doctor] it's good to see you , too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain . [patient] mm-hmm . [doctor] so , james , what happened to your back ? [patient] uh , i was golfing and i hurt my back when i went for my backswing . [doctor] okay . and did you feel a pop or a strain immediately or ? [patient] i f- felt the pop , and i immediately had to hit the ground . i had to just try and do anything to loosen up my back . [doctor] okay . and how long ago did this happen ? [patient] this was saturday morning . [doctor] okay . so , about four days ago ? [patient] mm-hmm . [doctor] okay . um , and what have you taken for the pain ? [patient] uh , i took some tylenol . i took some ibuprofen . [doctor] mm-hmm . [patient] i tried ice . i tried heat , but nothing really worked . [doctor] okay . and , h- how are you feeling now ? are you still in the same amount of pain ? [patient] uh , by monday morning , it loosened up a little bit , but it's still pretty sore . [doctor] okay . any other symptoms like leg weakness , pain in one leg , numbing or tingling ? [patient] uh , i actually felt , um ... i had a struggle in my right foot like dropped foot . i had some struggling with my right leg . i felt that for a while , and it got a little bit better this morning but not much . [doctor] okay . all right . um , so , are you ... how are you doing walking around ? [patient] uh , uh , uh , i'm , i'm not going anywhere fast or doing anything strenuous but i can walk around a little bit . [doctor] uh- . [patient] not too fast . [doctor] all right . okay . um , and any history with your back in the past ? [patient] i actually had surgery about 10 years ago on my lower back . [doctor] okay . all right . now , tell me a little bit about your , your heart failure . you know , i have n't seen you in a while . [patient] mm-hmm . [doctor] how are you doing with your diet ? [patient] um , been pretty good t- taking my medications , watching my diet , trying to , uh , trying to exercise regularly , too . [doctor] okay . so , you're avoiding the salty foods like we had talked about ? [patient] yes . [doctor] okay . and any weight gain or swelling in your legs recently ? [patient] a little bit of weight gain over the summer but nothing , nothing too radical , nothing more than five pounds . [doctor] okay . all right . and any problems laying flat while you go to bed ? [patient] no . [doctor] okay . uh , and lastly , what about your diabetes ? how are you doing with , with that diet ? i remember you have somewhat of a sweet tooth . [patient] yeah . [doctor] jelly beans ? [patient] i love jelly beans , yeah , yeah . that's been a struggle , but i'm getting through it . [doctor] okay . all right . um , and you're watching your blood sugars at home ? [patient] mm-hmm . i monitor it regularly . not always, i can forget, , but i'm pretty good about my measuring it . [doctor] okay . and you are still on your metformin ? [patient] yes . [doctor] okay . all right . all right . now , i know the nurse did a review of symptoms sheet when you checked in . [patient] mm-hmm . [doctor] i know that you were endorsing the back pain- [patient] mm-hmm . [doctor] . and maybe a little weakness in your right leg . um , any other symptoms ? i know we went through a lot . [patient] no . [doctor] okay . um , so , i wan na go ahead and move on to a physical exam , okay ? [patient] mm-hmm . [doctor] hey , dragon , show me the vital signs . so , here in the office , you know , your vital signs look great . they look completely normal , which , which is really good . [patient] good . [doctor] okay ? so , i'm just gon na check you out , and i'm gon na let you know what i find , okay ? [patient] mm-hmm . [doctor] lean up . okay . all right . so , on your physical exam , everything seems fine . [patient] good . [doctor] on your heart exam , i do appreciate a 2 out of 6 systolic ejection murmur , which we've heard in the past- [patient] mm-hmm . [doctor] . so that's stable . [patient] okay . [doctor] on your back exam , you do have some pain to palpation of the lumbar 5 or lumbar spine- [patient] mm-hmm . [doctor] at the level of l5 . [patient] okay . [doctor] you have , you know , decreased range of motion with flexion and extension , and , um , you have a positive straight leg raise . uh , for your strength , you do have a 4 out of 5 on your right and 5 out of 5 on your left . [doctor] so , what does that mean ? what does all that mean ? so , that basically means that , you know , i , i think that you probably , you know , have injured your , your back with a muscle strain , but we're gon na look at some of your results , okay ? [patient] okay , sure . [doctor] hey , dragon , show me the back x-ray . so , in reviewing the results of your back x-ray , this is a normal x-ray of your lumbar spine . there's good boney alignment . i do n't see any abnormality there , which is not surprising based on the history , okay ? [doctor] hey , dragon , show me the diabetic labs . and this is just ... i just wanted to check your last , uh , diabetic labs that we did on you . uh , it looks like your hemoglobin a1c has been a little high at 8 . i'd like to see that a little bit lower around 7 , okay ? [patient] okay . [doctor] um , so , let's just talk a little bit about my assessment and my plan for you . um , so , for your first problem , i think you have an acute lumbar , um , strain . [patient] mm-hmm . [doctor] and i wan na go ahead and prescribe meloxicam 15 milligrams once a day , and i'd like to refer you to physical therapy to kind of strengthen that area . now , if you're still having symptoms , i wan na go ahead and , uh , order an mri- [patient] mm-hmm . [doctor] . just to make sure that you do n't have any disc herniation or anything like that , okay ? [patient] that's fine . [doctor] how does that sound ? [patient] no problem . [doctor] hey , dragon , order meloxicam 15 milligrams once a day . for your next problem , your type 2 diabetes , i would like to increase your metformin to 1,000 milligrams twice daily- [patient] mm-hmm . [doctor] . and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months . [patient] okay . [doctor] all right ? hey , dragon , order a hemoglobin a1c . and for your congestive heart failure , uh , i think you're doing really well with it . um , you know , i wan na just continue you on your current medications , your lisinopril and your lasix . now , do you need a refill- [patient] actually , i- [doctor] of the lisinopril ? [patient] actually , i do . [doctor] okay . hey , dragon , order a refill of lisinopril 20 milligrams once a day . and so , the nurse will come in . she's gon na help you get checked out . i wan na see you again in a couple weeks , okay ? [patient] that's fine . [doctor] um , any questions ? [patient] not at this point . [doctor] okay . hey , dragon , finalize the note .

CHIEF COMPLAINT Back pain. HISTORY OF PRESENT ILLNESS James Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain. The patient states he was golfing and hurt his back. This happened approximately 4 days ago when he felt a pop in his back. The patient notes that he immediately hit the ground trying to loosen up his back. He reports taking some Tylenol, ibuprofen, and using ice and heat which did not relieve the pain. By Monday morning it loosened up a little bit, but it is still pretty sore. He had some right lower extremity weakness and some drop foot that he felt that for a while, and it got a little better this morning but not much. He had surgery about 10 years ago in his lower back. Regarding his congestive heart failure, he has been watching his diet and trying to exercise regularly. He is avoiding the salty foods and has been compliant with medications. He has gained a little weight over the summer but nothing more than 5 pounds. He has no problems lying flat to go to bed. Regarding his diabetes, he is watching his blood sugars at home, not always consistently. He is still on his metformin. REVIEW OF SYSTEMS • Constitutional: Denies weight loss. Endorses weight gain. • Musculoskeletal: Endorses back pain. Endorses right leg weakness and drop foot. PHYSICAL EXAMINATION • Cardiovascular: Grade 2/6 systolic ejection murmur, stable. • Musculoskeletal: Examination of his back reveals pain to palpation at L5. Decreased range of motion with flexion and extension. Positive straight leg raise. Strength is 4/5 on the right and 5/5 on the left. Results: X-ray lumbar spine, ordered and obtained in the office today, is unremarkable with good bony alignment. Hemoglobin A1c is elevated at 8. ASSESSMENT AND PLAN James Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain. Acute lumbar strain. • Medical Reasoning: The patient reports feeling a 'pop' and immediate pain while golfing approximately 4 days ago. He has tried Tylenol and ibuprofen without significant relief. • Additional Testing: If he continues to have pain, we will obtain an MRI for further evaluation. • Medical Treatment: Initiate meloxicam 15 mg once daily. • Specialist Referrals: We will refer him to physical therapy to work on strengthening the area. Diabetes type 2. • Medical Reasoning: He has been compliant with metformin and dietary modifications, but his recent hemoglobin A1c was 8. • Additional Testing: Repeat hemoglobin A1c in a couple of months. • Medical Treatment: Increase metformin to 1000 mg twice daily. Congestive heart failure. • Medical Reasoning: He is doing well from this standpoint. He has been compliant with his medications, dietary modifications, and regular physical activity. • Medical Treatment: Continue lisinopril 20 mg once daily and Lasix. Lisinopril was refilled today. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow-up in 2 weeks.

virtassist

D2N005

[doctor] hey , ms. hill . nice to see you . [patient] hi , dr. james , good to see you . [doctor] hey , dragon , i'm seeing ms. hill . she's a 41-year-old female , and what brings you in today ? [patient] um , i am having a lot of pain at the end of my right middle finger . [doctor] what did you do ? [patient] a little embarrassing . um , i got rear-ended , slow motor , uh , vehicle accident , and i got really angry with the person who hit me , so i went to flip him the bird , but i was a little too enthusiastic . [patient] and i hit the ceiling of the car . [doctor] okay . when did this happen ? [patient] uh , it was saturday , so about four , five days ago . [doctor] five days ago . what were you doing ? were you , like , stopped at a stoplight ? a stop sign ? [patient] yes . so i was stopped at a four-way stop , and it was not my turn to go . there were other cars going , and the person behind me just was n't watching . i think they were texting and rear-ended me . [doctor] how much damage to your car ? [patient] uh , not too much . the , the trunk crumpled up a little bit . [doctor] okay . and no other injuries ? just the finger ? [patient] just the middle finger . [doctor] so you would've escaped this accident without any injuries ? [patient] yes . uh , i'm not proud . [doctor] okay . um , so four days of right middle finger pain- [patient] yes . [doctor] . after a motor vehicle accident . [patient] yes . [doctor] all right . um , let's look at your x-ray . hey , dragon , show me the last x-ray . so what i'm seeing here is on the tip of this middle finger , you actually have a fracture . so you have a distal phalanx fracture in the middle finger . very ... [patient] great . [doctor] very interesting . let me check it out . um , so does it hurt when i push right here ? [patient] yes . [doctor] and does that hurt ? [patient] very much so . [doctor] what about down here ? [patient] no . [doctor] okay . so generally , your exam is normal other than you've got tenderness over your distal phalanx of your right middle finger . um , so your diagnosis is distal phalanx fracture of the middle finger or the third finger . and i'm gon na put you on a little bit of pain medicine just to help , just , like , two days' worth . okay , so tramadol , 50 milligrams , every six hours as needed for pain . i'm gon na dispense eight of those . [patient] okay . [doctor] and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ? [patient] yes . so i'm taking digoxin for afib . will the tramadol be okay with that ? [doctor] it will be okay . so you have atrial fibrillation . [patient] yes . [doctor] you take digoxin . all right . any other questions for me ? [patient] no , that's it . thank you . [doctor] you're welcome . hey , dragon , go ahead and finalize the recording , and , uh , come with me . we'll get you checked out .

CC: Right middle finger pain. HPI: Ms. Hill is a 41-year-old female who presents today for an evaluation of right middle finger pain after she was rear-ended in a motor vehicle accident. She has no other injuries. CURRENT MEDICATIONS: Digoxin PAST MEDICAL HISTORY: Atrial Fibrillation EXAM Examination of the right middle finger shows tenderness over the distal phalanx. RESULTS X-rays of the right middle finger, 3 views obtained on today's visit shows a comminuted distal phalanx fracture. IMPRESSION Right middle finger distal phalanx fracture. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I recommend a prescription for Tramadol 50 mg every 6 hours as needed for pain, dispense 8. She is provided a finger splint and will return in 2 weeks for a follow-up x-ray. All questions were answered.

virtassist

D2N006

[doctor] hi , anna . how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] all right . [doctor] so , anna is a 44-year-old female with a past medical history significant for arthritis , gout , and reflux , who presents today for follow up of her chronic problems . [doctor] so , anna , it's been probably about six months since i've seen you . how are you doing ? [patient] i'm doing okay . um , my arthritis is starting to get better . um , i've been trying to move my body , doing pilates , lifting weights , um , and that's , kind of , helped me build up some muscle , so the joint pain is , has been going away . [doctor] okay . yeah . i know you were having , you know , some problems with your right knee , uh , and we sent you for physical therapy . so , so that's going well ? [patient] yeah . the physical therapy's gone really well . i've built up my strength back and it's been really great . [doctor] okay . so you feel like you're able to walk a little bit further now ? [patient] yup . i'm walking about a mile , a mile and a half a day . [doctor] okay . great . that's good . i'm glad to hear that . okay . [doctor] and then , in terms of your gout , um , how are you doing with that ? i know you had an episode of gout of your , your right first big toe , um , about two months ago . how are you doing with that ? [patient] i'm doing , doing well . the medication helped it , you know , go down and go away . hopefully , , it does n't come back . [doctor] okay . and are you taking the allopurinol that i prescribed ? [patient] yes . [doctor] okay . and no issues with that ? [patient] nope . [doctor] okay . great . um , no further flare ups ? [patient] no . [doctor] okay . great . all right . [doctor] and then , you know , how about your reflux ? we had placed you on , um , omeprazole , you know , to help with some of those symptoms and i know that you were gon na do some dietary modifications . how are you doing with that ? [patient] so , i started to make some dietary modifications . unfortunately , i have n't cut the stone out quite yet . um , i've still been having some episodes and , and throwing up in the mornings , um , things like that . [doctor] you're throwing up in the morning ? [patient] yup . [doctor] like , just , like , reflux into your throat or are you actually vomiting ? [patient] um , actually vomiting . [doctor] okay . that's a problem . [patient] yup . [doctor] all right . well , um , let's talk about any other symptoms that you might have . have you had any abdominal pain ? um , diarrhea ? um , do you feel like your belly's bigger than usual ? [patient] um , the , the first and the last . so , i've been having some abdominal pain and then i feel like i'm bloated all the time . [doctor] okay . and when was your last bowel movement ? [patient] uh , probably two days ago . [doctor] okay . was it normal ? [patient] yes . [doctor] okay . any blood ? [patient] no . [doctor] okay . all right . and any weight loss ? anything like that ? [patient] no , not that i've noticed . [doctor] okay . and any fever or chills ? [patient] no . [doctor] okay . all right . uh , well , sounds like we just did the review of systems with you . it sounds like you're endorsing this , you know , nausea , vomiting , abdominal distension . um , any other symptoms ? [patient] no . [doctor] no ? okay . all right . well , i wan na go ahead and do a quick physical exam . okay ? [doctor] hey , dragon , show me the vital signs . all right . well , your , your vital signs here look quite good . all right . so , i'm , i'm reassured by that . i'm just gon na check out your heart and lungs and your belly and , and l- let you know what i find , okay ? [patient] okay . [doctor] all right . so , on physical examination , you know , everything looks good . your heart sounds good . your lungs sound good . you know , on your abdominal exam , you do have some pain to your right upper quadrant when i press on it , um , and there's no rebound or guarding and there's no peritoneal signs and your right knee does show a little bit of , uh , an effusion there and there's , uh , some slight pain to palpation and some decreased range of motion . [doctor] so what does that mean , you know ? that means that you have some findings on your belly exam that concern me about your gall bladder , okay ? so , we'll have to look into that and then , um , your right knee looks a little swollen , but you know , we know you have some arthritis there , okay ? [patient] okay . [doctor] let's take a look at some of your results . hey , dragon , show me the autoimmune panel . hey , dragon , show me the autoimmune labs . [doctor] okay . so looking at your autoimmune panel here , you know , we sent that because , you know , you're young and you have , you know , arthritis and gout and that type of thing and everything seemed to be fine . [patient] okay . [doctor] hey , dragon , show me the right knee x-ray . [doctor] so , looking here at your right knee x-ray , you know , there's no fracture or anything , but you know , it does show that you do have that residual arthritis there , um , that we're , you know , we're working on improving so that we do n't have to do some type of surgery or intervention , okay ? [patient] okay . [doctor] so let's talk a little bit about my assessment and plan for you , okay ? so , for your first problem , um , your reflux and your nausea and vomiting , uh , i wan na go ahead and get a right upper quadrant ultrasound to rule out any gallstones , okay ? um , and then i'm gon na check some labs on you . okay ? [patient] okay . [doctor] i want you to continue on the omeprazole , 40 milligrams , once a day and continue with those dietary modifications . [doctor] um , for your second problem , your gout , um , you know , everything seems controlled right now . let's continue you on the allopurinol , 100 milligrams , once a day . um , do you need a refill of that ? [patient] yes , i do actually . [doctor] hey , dragon , order allopurinol , 100 milligrams , once daily . [doctor] and then from your last problem , your arthritis , i'm very pleased with how your right knee is doing and i want you to continue pilates and using the knee and let me know if you have any issues and we can , and we can talk about further imaging or intervention at that time , okay ? [patient] okay . [doctor] any questions ? [patient] uh , no . that's it . [doctor] okay . great . hey , dragon , finalize the note .

CHIEF COMPLAINT Follow-up of chronic problems. HISTORY OF PRESENT ILLNESS Anna Mitchell is a 44-year-old female with a past medical history significant for arthritis, gout, and reflux, who presents today for follow-up of her chronic problems. It has been about 6 months since I last saw the patient. The patient reports her arthritis is starting to get better. She has been trying to move her body with pilates and lifting weights. This has helped build up some muscles and her joint pain has reduced. The patient has also continued to attend physical therapy, which she feels has been beneficial. Ms. Mitchell had an episode of gout of her right first big toe about 2 months ago. She states she is doing well on the allopurinol 100 mg once daily and has had no further flare ups. Regarding her acid reflux, she was placed on omeprazole 40 mg once a day to help with some of the symptoms she was having. She started to make some dietary modifications, but she still needs to make more progress. She reports episodes of vomiting in the morning. The patient also has abdominal pain and bloating. Her last bowel movement was 2 days ago, and it was normal. She denies blood in her stool. The patient denies unexplained weight gain or loss, fevers, chills. REVIEW OF SYSTEMS • Constitutional: Denies fevers, chills, or weight loss. • Gastrointestinal: Denies hematochezia, melena. Endorses vomiting, abdominal pain, and bloating. • Musculoskeletal: Endorses joint pain. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds. • Gastrointestinal: Pain to palpation of the right upper quadrant. No rebound or guarding. No peritoneal signs. • Musculoskeletal: Right knee shows a little effusion. Slight pain to palpation. Some decreased range of motion. RESULTS Autoimmune panel is within normal limits. X-ray of the right knee demonstrates residual arthritis. No fractures noted. ASSESSMENT AND PLAN Anna Mitchell is a 44-year-old female with a past medical history significant for arthritis, gout, and reflux, who presents today for follow-up of her chronic problems. Acid reflux with nausea and vomiting. • Medical Reasoning: She reports episodes of vomiting in the morning, as well as abdominal pain and bloating. She has been compliant with omeprazole and has made a few dietary modifications. • Additional Testing: We will order an ultrasound of her right upper quadrant, as well as additional labs, to rule out biliary etiology. • Medical Treatment: Continue omeprazole 40 mg once daily. • Patient Education and Counseling: I encouraged her to continue with dietary modifications. Gout. • Medical Reasoning: Her flares are well controlled on allopurinol. • Medical Treatment: Continue allopurinol 100 mg once daily. This was refilled today. Arthritis. • Medical Reasoning: She is doing well and has remained active since her last visit. Physical therapy has also been beneficial for her. Her right knee x-ray demonstrated residual arthritis but was otherwise normal. • Patient Education and Counseling: I advised her to continue pilates and using the knee. She will contact me if she has any issues and we can consider further imaging or intervention at that time. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N007

[doctor] and why is she here ? annual exam . okay . all right . hi , sarah . how are you ? [patient] good . how are you ? [doctor] i'm good . are you ready to get started ? [patient] yes , i am . [doctor] okay . so sarah is a 27-year-old female here for her annual visit . so , sarah , how have you been since the last time i saw you ? [patient] i've been doing better . um , i've been struggling with my depression , um , a bit more just because we've been trapped really inside and remotely over the past year , so i've been struggling , um , off and on with that . [doctor] okay . uh , and from looking at the notes , it looks like we've had you on , uh , prozac 20 milligrams a day . [patient] yes . [doctor] are , are you taking that ? [patient] i am taking it . i think it's just a lot has been weighing on me lately . [doctor] okay . um , and do you feel like you need an increase in your dose , or do you ... what are you thinking ? do you think that you just need to deal with some stress or you wan na try a , a different , uh , medication or ... [patient] i think the , the medication has helped me in the past , and maybe just increasing the dose might help me through this patch . [doctor] okay . all right . and , and what else has been going on with you ? i know that you've had this chronic back pain that we've been dealing with . how's that , how's that going ? [patient] uh , i've been managing it . it's still , um , here nor there . just , just keeps , um , it really bothers me when i sit for long periods of time at , at my desk at work . so i have ... it helps when i get up and move , but it gets really stiff and it hurts when i sit down for long periods of time . [doctor] okay , and do you get any numbing or tingling down your legs or any pain down leg versus the other ? [patient] a little bit of numbing , but nothing tingling or hurting down my legs . [doctor] okay , and does the , um , do those symptoms improve when you stand up or change position ? [patient] yeah , it does . [doctor] okay . all right . and any weakness in , in your legs ? [patient] no , no weakness , just , just the weird numbing . like , it's , like , almost like it's falling asleep on me . [doctor] okay . and are you able to , um , do your activities of daily living ? do you exercise , go to the store , that type of thing ? [patient] yeah , i am . it bothers me when i'm on my feet for too long and sitting too long , just the extremes of each end . [doctor] okay . and i know that you've had a coronary artery bypass grafting at the young age of 27 , so how's that going ? [patient] yeah , i had con- i had a congenital ... you know , i had a congenital artery when i was a baby , so , um , they had to do a cabg on me , um , fairly young in life , but i've been ... my heart's been doing , doing well , and arteries have been looking good . [doctor] okay . all right , well , let's go ahead and do a quick physical exam . um , so looking at you , you do n't appear in any distress . um , your neck , there's no thyroid enlargement . uh , your heart i hear a three out of six , systolic ejection murmur , uh , that's stable . your lungs otherwise sound clear . your abdomen is soft , and you do have some pain to palpation of your lumbar spine . uh , and you've had decreased flexion of your back . uh , your lower extremity strength is good , and there's no edema . so let's go ahead and look at some of your results . hey , dragon , show me the ecg . okay , so that looks basically unchanged from last year , which is really good . hey , dragon , show me the lumbar spine x-ray . hey , dragon , show me the back x-ray . great . so this looks good . that's also stable from last year . okay . so let's go ahead and , you know , my , my plan for you at this time , you know , from a chronic back pain standpoint , if you need , um , you know , some more physical therapy , and i can refer you to physical therapy to help with those symptoms that are kind of lingering . [patient] mm-hmm . [doctor] um , and we can always give you some pain medication if you , if you get some pain periodically with activity . how do you feel about that ? do you need some pain medication ? [patient] no , i think physical therapy is the right way to , way to start out on this . [doctor] okay . hey , dragon , order physical therapy referral . and then in terms of your depression , we talked about increasing your prozac , so we'll increase it from 20 milligrams to 40 milligrams . it's just one tablet once a day . [patient] okay . [doctor] um , and i'll send those to your pharmacy . does that sound okay ? [patient] that sounds great . [doctor] hey , dragon , order prozac , 40 milligrams , once a day . and then in terms of your ... the heart bypass that you've had ... let's go ahead and just order another echocardiogram for you , and i wan na continue you on the aspirin for now , okay ? [patient] okay . [doctor] hey , dragon , order an echocardiogram . hey , dragon , order aspirin 81 milligrams daily . okay , so the nurse will come in . she'll help you schedule those things , and we'll go from there , okay ? [patient] okay . [doctor] all right , take care . [patient] thank you . [doctor] hey , dragon , finalize the note .

CHIEF COMPLAINT Annual visit. HISTORY OF PRESENT ILLNESS The patient is a 27-year-old female who presents for her annual visit. The patient reports that she has been doing better since her last visit. She reports that she has been struggling with her depression off and on for the past year. The patient notes that it might be due been trapped inside and remotely over the past year. She reports that she is taking Prozac 20 mg, but she believes that it has been weighing on her lately. She notes that an increase in her Prozac dose might be beneficial for her at this time. The patient reports that she has had chronic back pain that she has been managing. She reports that she experiences stiffness and pain when she sits or stands for long periods of time at her desk at work. She reports that it helps when she gets up and moves. She reports that she has a little bit of numbness down her legs, but no tingling or pain down her legs. She reports that the symptoms improve when she stands up or changes positions. She denies any weakness in her legs. She reports that she has had a coronary artery bypass grafting. She reports that she had a congenital artery when she was a baby and they had to do a CABG on her fairly young age. She reports that her heart has been doing well and her arteries have been looking good. REVIEW OF SYSTEMS • Musculoskeletal: Endorses back pain. • Neurological: Endorses numbness in legs. • Psychiatric: Endorses depression. PHYSICAL EXAMINATION • Constitutional: in no apparent distress. • Neck: Supple without thyromegaly. • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: 3/6 systolic ejection murmur, stable. • Musculoskeletal: Pain to palpation of the lumbar spine. Decreased flexion of back. Lower extremity strength is good. RESULTS Echocardiogram appears unchanged in comparison to last year. X-rays of the lumbar spine stable in comparison to last year. ASSESSMENT The patient is a 27-year-old female who presents today for an annual followup of chronic conditions. Chronic back pain. • Medical Reasoning: She is experiencing worsened pain with sitting for extended periods of time. • Medical Treatment: Physical therapy referral ordered. Patient would like to defer pain medication at this time. Depression • Medical Reasoning: The patient was previously doing well on Prozac 20 mg once daily but feels as though she needs a higher dose at this time. • Medical Treatment: Increase Prozac to 40 mg once daily. Prescription submitted. History of coronary artery bypass graft. • Medical Reasoning: She is doing well at this time. We will continue to monitor this. • Medical Treatment: Echocardiogram ordered. Continue aspirin 81 mg daily.

virtassist

D2N008

[doctor] hi , stephanie . how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing okay . um , so i know the nurse talked to you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] so , stephanie is a 49-year-old female with a past medical history significant for congestive heart failure , kidney stones and prior colonoscopy who presents today for an abnormal lab finding . so , stephanie , i called you in today because your hemoglobin is low . um , how have you been feeling ? [patient] over the past couple of months , i've been really tired and dizzy . lately , i've been really just worn out , even just , you know , walking a mile or going to work , doing things that i've done in the past every day that have been relatively okay , and i have n't gotten tired . and now , i've been getting tired . [doctor] okay , yeah . i , you know , the nurse told me that you had called with these complaints . and i know that we have ordered some labs on you before the visit . and it did , it c- you know , your , your , your hemoglobin is your red blood cell count . and now , and that came back as a little low on the results , okay ? so , have you noticed any blood in your stools ? [patient] uh , no , i have n't . i did about three years ago , um , and i did a colonoscopy for that , but nothing since then . [doctor] okay , yeah . i remember that , okay . and how about , you know , do your stools look dark or tarry or black or anything like that ? [patient] no , nothing like that . [doctor] okay . and have you been , um , having any heavy menstrual bleeding or anything like that ? [patient] no , not that i've noticed . [doctor] okay , all right . and any , have you passed out at all , or anything like that ? any weight loss ? [patient] no , no weight loss or passing out . i have felt a bit dizzy , but it has n't l- led to me passing out at all . [doctor] okay . so , you endorse some dizziness . you endorse some fatigue . have you , but you have n't had any weight loss , loss of appetite , anything like that ? [patient] no , nothing like that . [doctor] okay , all right . so , you know , let's talk a little bit about that colonoscopy . i know you had a colonoscopy about three years ago and that showed that you had some mild diverticuli- diverticulosis . um , no issues since then ? [patient] nope , no issues since then . [doctor] okay , all right . and then i know that , uh , you know , you have this slightly reduced heart function , you know , your congestive heart failure . how have you been doing watching your salt intake ? i know that that's kind of been a struggle for you . [patient] um , it's been more of a struggle recently . i've been traveling a lot . i went up to vermont , um , to go , um , explore the mountains . and along the way i stopped at , you know , mcdonald's and got two cheeseburgers . and so , i , i could be doing better . i've noticed some swelling in my , my legs . um , but nothing too extreme that where i thought i should call . [doctor] okay , all right . and any shortness of breath or problems lying flat at night , anything like that ? [patient] no , nothing like that . [doctor] okay , all right . and then in terms of the kidney stones , i know that you had those a couple years ago , as well . any recent flare ups ? have you had any , any back pain , flank pain , anything like that ? [patient] no , nothing like that . [doctor] okay . any blood in your urine that you've seen ? [patient] no . [doctor] okay , all right . um , okay . well , i know that the nurse did a review of system sheet when you came in . and we've just talked a lot about your , your s- your symptoms , you know , your dizziness , your fatigue and that type of thing . anything else that i might have missed , fever chills , any nasal congestion , sore throat , cough ? [patient] uh , i've had a little bit of nasal congestion just because with the seasons changing , i , i get seasonal allergies . but everything else has been okay . [doctor] okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] hey , dragon , show me the vital signs . so , here in the office today , your vital signs look great . your blood pressure is fine . your heart rates r- right where it should be , which is good , okay ? i'm just gon na do a quick exam . and i'll let you know what , what i find , okay ? [patient] okay . [doctor] all right . so , your physical , physical examination looks fine . so , on your heart exam , i do hear a three out of six systolic ejection murmur , which we've heard in the past , okay ? and on your lower extremities , i do notice some trace to one plus pitting edema in your ankles , which is probably from the salt intake , okay ? [patient] mm-hmm . [doctor] so , we'll talk about that . i wan na just look at some of your results , okay ? [patient] okay . [doctor] hey , dragon , show me the echocardiogram . so , i just wanted to go over the results of your last echocardiogram , that was about six months ago . that shows that you do have the low pumping function of , of your heart at about 45 % , which is not terrible . and it does show that you have some moderate mitral regurgitation . so , that's that slight heart murmur i heard in your exam , okay ? hey , dragon , show me the hemoglobin . and here , this is the hemoglobin that i was referring to . it's low at 8.2 , okay ? so , we'll have to talk a little bit about that , all right ? [doctor] so , let me go over a little bit about my assessment and my plan for you , okay ? so , for you first problem this new anemia , uh , i wan na go ahead and send off some more labs and anemia profile , just to see exactly what type of anemia we're dealing with . i also wan na go and refer you back to the gastroenterologist for another evaluation , okay ? hey , dragon , order referral to gastroenterology . so , they're gon na do , uh , probably do an endoscopy and another colonoscopy on you . um , but again , i wan na send off those labs just to make sure that it's not something else , okay ? [patient] okay . [doctor] for your next problem your congestive heart failure , um , i do think you're retaining a little bit of fluid . so , i'm gon na go ahead and start you on some lasix 40 milligrams once a day . i want you to continue you on your toprol 50 milligrams daily . and as well your , as well , as your lisinopril 10 milligrams a day . i really want you to watch your salt intake , okay ? get a scale , weigh yourself every day . and call me if your weight starts to go up , okay ? [patient] okay . [doctor] 'cause i might need to give you more diuretic . [patient] all right . [doctor] and for your last problem your kidney stones , uh , i think everything seems to be fine right at this time . again , continue to watch your diet and stay hydrated . um , and i know that might be a little difficult with the diuretic , but do your best . uh , and give me a call if you have any question , okay ? [patient] okay . [doctor] all right . any questions right now ? [patient] not that i can think of . [doctor] okay , great . hey , dragon , finalize the note .

CHIEF COMPLAINT Abnormal labs. HISTORY OF PRESENT ILLNESS Ms. Stephanie Diaz is a 49-year-old female with a past medical history significant for congestive heart failure, kidney stones, and prior colonoscopy, who presents today for abnormal labs. The patient reports she has been really tired and dizzy over the past couple of months. She reports these symptoms while walking a mile, going to work, and performing daily tasks. She denies any blood in her stools recently but notes she had blood in her stool about 3 years ago and had a colonoscopy for that. She denies any black, tarry stools, heavy menstrual bleeding, unintentional weight loss, or syncope. Ms. Diaz had a colonoscopy about 3 years ago due to blood in her stool. This showed mild diverticulitis. She denies issues since that time. Regarding her congestive heart failure, she states she is not doing well with her salt intake. This has been more of a struggle recently as she has been traveling a lot. She has noticed some swelling in her legs but nothing too extreme. The patient denies recent issues with kidney stones. She denies low back pain, flank pain, or blood in her urine. Ms. Diaz notes she has had some nasal congestion but attributes this to the season changing. She gets seasonal allergies but everything else has been okay. The patient denies fever, chills, sore throat, or cough. REVIEW OF SYSTEMS • Constitutional: Denies fevers, chills, or weight loss. Endorses fatigue. • Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies. • Cardiovascular: Denies dyspnea. • Respiratory: Denies cough, shortness of breath. • Gastrointestinal: Denies hematochezia, melena. • Musculoskeletal: Endorses bilateral leg swelling. • Neurological: Endorses dizziness. PHYSICAL EXAMINATION • Cardiovascular: Grade 3/6 systolic ejection murmur. • Musculoskeletal: Trace to 1+ edema in the bilateral ankles. RESULTS Echocardiogram demonstrates decreased ejection fraction of 45%. Moderate mitral regurgitation. Hemoglobin is 8.2. ASSESSMENT AND PLAN Ms. Stephanie Diaz is a 49-year-old female with a past medical history significant for congestive heart failure, kidney stones, and prior colonoscopy, who presents today for abnormal labs. Anemia. • Medical Reasoning: This is a new issue. Her recent hemoglobin level was low at 8.2, but she denies any signs of gastrointestinal bleeding or urinary tract bleeding, as well as any abnormal menstrual bleeding. Her colonoscopy from 3 years ago demonstrated mild diverticulosis. • Additional Testing: We will order an anemia profile for further evaluation. • Specialist Referrals: We will refer her back to gastroenterology for repeat evaluation with possible endoscopy and colonoscopy. Congestive heart failure. • Medical Reasoning: She has noticed some lower extremity edema. Her echocardiogram from 6 months ago demonstrated a reduced ejection fraction of 45%, as well as moderate mitral regurgitation. • Medical Treatment: We will initiate Lasix 40 mg once daily, and continue with Toprol 50 mg daily and lisinopril 10 mg daily. • Patient Education and Counseling: She should continue to limit her sodium intake. I advised her to monitor her daily weights and notify me if these start to increase. Kidney stones. • Medical Reasoning: She as asymptomatic denies any recent flare ups. • Patient Education and Counseling: I encouraged her to continue with dietary modifications and proper hydration. She will contact me with any questions or concerns. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N009

[doctor] hi , bryan . how are you ? [patient] i'm doing well . i'm a little sore . [doctor] yeah ? [patient] yeah . [doctor] all right , well , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] that's fine . [doctor] so bryan is a 55-year-old male with a past medical history significant for prior discectomy , who presents with back pain . so , bryan , what happened to your back ? [patient] you ... my wife made me push a , uh , refrigerator out through the other room , and when i was helping to move it , i felt something in my back on the lower right side . [doctor] okay , on the lower right side of this back ? [patient] yes . [doctor] okay . those wives , always making you do stuff . [patient] yes . [doctor] and what day did this happen on ? how long ago ? [patient] uh , this was about five days ago . [doctor] five days ago . [patient] and , you know , i have that history of discectomy . [doctor] yeah . [patient] and i'm just worried that something happened . [doctor] okay . all right . and , and what have you taken for the pain ? [patient] um , i have , uh , been taking ibuprofen . uh , and i tried once tylenol and ibuprofen at the same time , and that gave me some relief . [doctor] okay . all right . and have you had any symptoms like pain in your legs or numbing or tingling ? [patient] um , no , nothing significant like that . [doctor] okay , just the pain in your back . [patient] just the pain in the back . it hurts to bend over . [doctor] okay , and any problems with your bladder or your bowels ? [patient] no , no . [doctor] i know the nurse said to review a symptom sheet when you checked in . [patient] mm-hmm . [doctor] and i know that you were endorsing the back pain . any other symptoms ? chest pain ? shortness of breath ? abdominal pain ? [patient] no . [doctor] nausea ? vomiting ? [patient] no other symptoms . [doctor] okay . all right . well , let's go ahead and do a quick physical exam . hey , dragon , show me the vital signs . so your vital signs here in the office look really good . you do n't have a fever . your blood pressure's nice and controlled . so that ... that's good . i'm just gon na check out your back and your heart and your lungs , okay ? [patient] okay . [doctor] okay , so on physical examination , you know , your heart sounds great . there's ... it's a regular rate and rhythm . your lungs are nice and clear . on your back exam , you do have some pain to palpation of the right lumbar spine , uh , in the paraspinal muscles along with decreased flexion and extension of the back , and you have a positive straight leg on the right . or positive straight leg raise on the right , uh , but your strength is good bilaterally in your lower extremities . so that means that i think that you've injured your back . [patient] okay . [doctor] uh , but , you know , i think it's something that we can , we can fix , okay ? [patient] okay , you do n't think there's anything wrong with the ... where i had the surgery before . [doctor] i do n't think so . [patient] okay . [doctor] let's took at some of your results . hey , dragon , show me the back x-ray . so this is an x-ray of your lumbar spine . you know , there's good bony , bony alignment . i do n't see any fracture or anything like that . so that's a good sign . um , hey , dragon . show me the labs . and your labs here all look good , so i'm , i'm happy to see that . uh , so let's talk a little bit about my assessment and my plan for you , okay ? [patient] okay . [doctor] so i ... my assessment for your first problem , your back pain . i think you have a lumbar strain . i do n't think that anything else is going on , but i wan na go ahead and order an mri- [patient] okay . [doctor] just to be sure . [patient] okay . [doctor] okay ? and then i'm gon na prescribe you some meloxicam 15 milligrams once a day along with some ultram , 50 milligrams every four hours as needed , okay ? [patient] okay . [doctor] um , and then we'll go ahead and refer you to some physical therapy once we get the mri results back , okay ? [patient] should i continue to take the tylenol and the ibuprofen ? [doctor] you can stop the ibuprofen . [patient] okay . [doctor] you can take tylenol if you want . [patient] okay . [doctor] you know to call me if , if you need anything . [patient] okay . [doctor] okay ? [patient] okay . [doctor] any questions , uh , bryan ? [patient] no , no questions . [doctor] okay . hey , dragon , finalize the note .

CHIEF COMPLAINT Back pain. HISTORY OF PRESENT ILLNESS Bryan Smith is a 55-year-old male with a past medical history significant for and prior discectomy, who presents with back pain. The patient reports he felt something in the lower right side of his back while pushing a refrigerator up through another room. This happened about 5 days ago. The patient experiences pain while bending over. He has a history of a discectomy. He is worried that something happened. He has been taking ibuprofen, which has not been beneficial alone. With the combination of Tylenol and ibuprofen, he experiences symptomatic relief. He denies numbness and tingling in his legs, and any problems with his bladder or bowels. REVIEW OF SYSTEMS • Cardiovascular: Denies chest pain or dyspnea on exertion. • Respiratory: Denies shortness of breath. • Gastrointestinal: Denies hematemesis, hematochezia, melena, heartburn, or abdominal pain. • Genitourinary: Denies urinary urgency, pain, or incontinence. • Musculoskeletal: Endorses lower right side back pain. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds. • Musculoskeletal: Pain to palpation to the right lumbar spine and the paraspinal muscles. Decreased flexion and extension of the back. Positive straight leg raise on the right. Strength is good bilaterally in the lower extremities. RESULTS X-ray of the lumbar spine is unremarkable. Normal bony alignment. No fractures were noted. Labs: Within normal limits. ASSESSMENT AND PLAN Bryan Smith is a 55-year-old male with a past medical history significant for prior discectomy, who presents with back pain. Lumbar strain. • Medical Reasoning: He reports right-sided low back after moving a refrigerator approximately 5 days ago. X-ray of his lumbar spine is unremarkable. I do not believe this is related to his previous discectomy. • Additional Testing: We will order a MRI of the lumbar spine for further evaluation. • Medical Treatment: Initiate meloxicam 15 mg once daily, as well as Ultram 50 mg every 4 hours as needed. • Specialist Referrals: We will refer him to physical therapy to be started after we get his MRI results back. • Patient Education and Counseling: I advised the patient to discontinue the use of ibuprofen, but he may continue using Tylenol if he wishes. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N010

[doctor] hi keith , how are you ? [patient] ah , not too good . my blood sugar is n't under control . [doctor] and , uh , so keith is a 58-year-old male here for evaluation of high blood sugar . so , what happened ? ha- have you just been taking your blood sugars at home and noticed that they're really high ? or ? [patient] yeah i've been taking them at home and i feel like they've been creeping up slightly . [doctor] have- ... what have they been running , in like the 200's or 300's ? [patient] 300's . [doctor] they've been running in the 300's ? and tell me about your diet . have you been eating anything to spark- ... spike them up ? [patient] to be honest my diet has n't changed much . [doctor] okay . have you- ... go ahead . [patient] actually it has n't changed at all . much of the same . [doctor] okay and what do you con- consider the same ? are you eating lots of sugar ? like , teas and coffees and- [patient] i do n't take sugar with my tea . [doctor] okay , all right . and how about , um , like any added sugars into any kind of processed foods or anything like that ? [patient] uh , i think most of my sugars come from fruit . [doctor] from what ? [patient] fruit . [doctor] fruit , okay . [patient] yeah . [doctor] all right . um , and have you been feeling sick recently ? have you had any fever or chills ? [patient] uh , i have not . [doctor] body aches , joint pain ? [patient] uh , a bit of joint pain . [doctor] multiple joints , or just one joint ? [patient] uh , my knee . uh , sorry , right knee to be more exact . [doctor] your right knee ? [patient] yeah . [doctor] okay . and what happened ? [patient] ah , to be honest , nothing much . i just noticed it when you said it . [doctor] okay , all right . um , and how about any nausea or vomiting or belly pain ? [patient] uh , i was nauseous a couple of days back but , uh , that's just because i was sitting in the back of a car . i hate that . [doctor] okay . all right . and no burning when you urinate or anything like that ? [patient] not at all . [doctor] okay . all right . so , um ... you know , i know that you've had this reflux in the past . how are you doing with that ? are you still having a lot of reflux symptoms or do you feel like it's better since we've put you on the protonix ? [patient] i think it's a bit better . uh , i do n't get up at night anymore with reflux and that's always a good thing . [doctor] okay , all right . and i know you have this history of congestive heart failure . have you noticed any recent , uh , weight gain or fluid retention ? [patient] um , not really . [doctor] no ? okay . um , and any problems sleeping while laying flat ? [patient] uh , i- i prefer to sleep on my side so i ca n't really say . [doctor] okay , but even then , you're flat . [patient] yup , yeah . [doctor] okay . all right . and i know that we had an issue with your right rotator cuff , is that okay ? [patient] it's surprisingly good now . [doctor] okay , all right . all right , well let's go ahead and we'll do a quick physical exam . so ... feeling your neck , i do feel like your thyroid's a bit enlarged here . um , your heart is nice and regular . your lungs are clear . your abdomen , um , is nice and soft . your right knee shows that you have some erythema and- and an insect bite with associated fluctuants . and , um , you have some lower extremity edema on the right hand side . so let's go ahead and look at some of your results . i know the nurse had reported these things and we ordered some labs on you before you came in . hey dragon , show me the vital signs . okay , well your- your vital signs look good , which is good . hey dragon , show me the lyme titer . okay , so , you know , your lyme titer is a little elevated , so i think we'll have to go ahead and- and look into that a little bit , okay ? [patient] makes sense . [doctor] that can certainly cause your blood sugar to be elevated . um , hey dragon , uh , show me the rapid strep . and you also have , uh , positive for strep . so i think we have some reasons as to why your blood sugar is so high . so my impression of you , you know , you have this hyperglycemia , which is probably related to some infections going on in your body . um , from a- a- a rapid strep standpoint we're gon na go ahead and treat you with penicillin or , i'm sorry , amoxicillin , 500 milligrams , three times a day . uh , make sure you take it all , even if you start feeling better , okay ? [patient] for sure . [doctor] hey dragon , order amoxicillin , 500 milligrams , three times a day for 10 days . um ... okay . and from ... , and from all- ... a positive lyme titer aspect , we should go ahead and order a western blot , just pcr to see if you have any , um , to see if it's actually acute lyme , okay ? [patient] okay . [doctor] okay . um , hey dragon , order a western blot pcr for lyme . okay . all right . well we'll go ahead and , um , the nurse will come in soon and she'll set you up with these tests , okay ? [patient] yeah . you said lyme . is that related to lyme disease ? [doctor] yes it is , yeah . [patient] you're certain i do n't have alpha-gal syndrome though , right ? i'm terrified of that one . [doctor] have what ? [patient] alpha-gal syndrome , the one where a tick bites you and you get an allergic reaction to meat . [doctor] yeah , i do n't think so . have you eaten meat over the last couple of days ? [patient] i have . [doctor] okay . well i- ... it's , you know , your blood sugar's elevated so you might be having an inflammatory response to that , but we'll go ahead and order some tests to look into it , okay ? [patient] that sounds good . [doctor] all right . call me if anything happens , okay ? [patient] definitely . [doctor] all right . hey dragon , finalize the note .

CHIEF COMPLAINT High blood sugar. HISTORY OF PRESENT ILLNESS The patient is a 58-year-old male who presents for evaluation of high blood sugar. The patient states he has been taking his blood sugars at home, and they have been in the 300 's. He notes that his diet has not changed much. He does not eat processed food, nor does he put sugar in his tea. The patient reports that he thinks the sugar in his diet is from fruit. He denies any fever, chills, or body aches. He endorses joint pain in his right knee; however, he notes that he just noticed the joint pain when asked. He states he was nauseous for a couple of days but that was because he was sitting in the back of a car. He denies any burning with urination. The patient has a history of congestive heart failure. He denies any recent weight gain or fluid retention. He has no problems laying flat. The patient has a history of right rotator cuff issues which he notes are doing well. He notes that his reflux is doing better. The patient reports that he no longer gets up at night from reflux. REVIEW OF SYSTEMS • Constitutional: Negative for fever, chills or unintentional weight changes. • Musculoskeletal: Positive for right knee pain. PHYSICAL EXAMINATION Neck • General Examination: Neck is supple, mild thyromegaly noted. Respiratory • Auscultation of Lungs: Clear bilaterally. Cardiovascular • Auscultation of Heart: Regular rate and rhythm. Gastrointestinal • Examination of Abdomen: Soft. Musculoskeletal • Examination: Right knee shows some erythema and insect bite with associated fluctuance. Trace edema in the right lower extremity.ß RESULTS Lyme titer: elevated. Rapid strep test: positive. ASSESSMENT AND PLAN The patient is a 58-year-old male who presents for evaluation of high blood sugar. Hyperglycemia • Medical Reasoning: This is likely related to an inflammatory response as the patient had an elevated Lyme titer and positive rapid strep test. • Additional Testing: We will order a western blot PCR to evaluate for Lyme disease. • Medical Treatment: We are going to treat him with amoxicillin 500 mg 3 times a day for 10 days. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N011

[doctor] hi , roger . how are you ? [patient] hey . good to see you . [doctor] good to see you . are you ready to get started ? [patient] yes , i am . [doctor] roger is a 62 year old male here for emergency room follow-up for some chest pain . so , roger , i heard you went to the er for some chest discomfort . [patient] yeah . we were doing a bunch of yard work and it was really hot over the weekend and i was short of breath and i felt a little chest pain for probably about an hour or so . so , i got a little nervous about that . [doctor] okay . and had you ever had that before ? [patient] no , i never have , actually . [doctor] okay . and- [patient] whose mic is on ? i'm in . [doctor] okay . and , um , how are you feeling since then ? [patient] um , after , uh , we were done , i felt fine ever since , but i thought it was worth looking into . [doctor] okay . and no other symptoms since then ? [patient] no . [doctor] okay . and any family history of any heart disease ? [patient] uh , no , actually . not , not on my , uh , uh , on my immediate family , but i have on my cousin's side of the family . [doctor] okay . all right . all right . and , um , you know , i know that you had had the , uh , knee surgery- [patient] mm-hmm . [doctor] a couple months ago . you've been feeling well since then ? [patient] yeah . no problem in , uh , rehab and recovery . [doctor] okay . and no chest pain while you were , you know , doing exercises in pt for your knee ? [patient] no . that's why last week's episode was so surprising . [doctor] okay . all right . and in terms of your high blood pressure , do you know when you had the chest pain if your blood pressure was very high ? did they say anything in the emergency room ? [patient] um , they were a little concerned about it , but , uh , they kept me there for a few hours and it seemed to regulate after effect . so , it , it did n't seem to be a problem when i , when i went home . [doctor] okay . and , and i see here that it was about 180 over 95 when you went into the emergency room . has it been running that high ? [patient] uh , usually no . that's why it was so surprising . [doctor] okay . all right . all right . well , let's go ahead and we'll do a quick physical exam . so , looking at you , you know , i'm feeling your neck . i do feel a little enlarged thyroid here that's not tender . you have a carotid bruit on the right hand side and , uh , your lungs are clear . your heart is in a regular rate and rhythm , but i do hear a three out of six systolic ejection murmur . your abdomen is nice and soft . uh , there is the healed scar on your right knee from your prior knee surgery , and there's no lower extremity edema . [doctor] so , let's look at some of your results , okay ? [patient] mm-hmm . [doctor] hey , dragon , show me the blood pressure . yeah . and here , your blood pressure's still high , so we'll have to talk about that . um , hey , dragon , show me the ekg . so , here you- that's good , your , your ekg- [patient] mm-hmm . [doctor] . here is normal , so that's , that's very encouraging . um , i know that they had the echocardiogram , so let's look at that . hey , dragon , show me the echocardiogram . okay . so , looking at this , you know , you do have a little bit of a , a low pumping function of your heart , which , you , you know , can happen and we'll have to look into that , okay ? [patient] mm-hmm . [doctor] so , you know , my impression is is that you have this episode of chest pain , um , that could be related to severe hypertension or it could be related to some heart disease . so , what i'd like to go ahead and do is , number one , we'll put you on , um ... we'll change your blood pressure regimen . we'll put you on carvedilol , 25 milligrams twice a day . that helps with coronary disease as well as your pumping function of your heart . um , i wan na go ahead and order a cardiac catheterization on you and make sure that we do n't have any blockages in your heart arteries responsible for the chest pain . [doctor] for the high blood pressure , we're gon na add the carvedilol and i want you to continue your lisinopril 10 milligrams a day and i wan na see , uh , how your blood pressure does on that regimen , okay ? [patient] okay . sounds good . [doctor] all right . so , the nurse will be in soon and i'll ... we'll schedule that cath for you , okay ? [patient] you got it . [doctor] hey , dragon , finalize the note .

HISTORY OF PRESENT ILLNESS Roger Nelson is a 62-year-old male who presents for emergency room follow-up for chest pain. The patient was doing yard work over the weekend when he began to feel short of breath and a full chest pain for approximately hour. He denies a history of chest pain. The patient notes that after he finished he felt fine. He has not had any other symptoms since that time. He denies a family history of heart disease. The patient underwent right knee surgery a couple of months ago and has been feeling well since then. He has been in rehab and recovery. He denies chest pain while doing exercises in physical therapy for his knee. His blood pressure was noted to be 180/95 mmHg when he visited the emergency room. He notes that his blood pressure has not been as high as usual. PHYSICAL EXAMINATION Neck • General Examination: I do feel a little large thyroid that is not tender. She has a carotid bruit on the right side. Respiratory • Auscultation of Lungs: Clear bilaterally. Cardiovascular • Auscultation of Heart: Regular rate and rhythm, but I do hear 3/6 systolic ejection murmur. Gastrointestinal • Examination of Abdomen: Soft. There is a healed scar on the right knee from prior knee surgery. Musculoskeletal • Examination: There is no lower extremity edema. RESULTS Blood pressure is elevated. EKG is normal. Echocardiogram demonstrates decreased ejection fraction. ASSESSMENT AND PLAN The patient is a 62-year-old male who presents for emergency room follow-up. He presented to the emergency room for chest pain and elevated blood pressure of 180/95. His EKG from the emergency room was normal, but ejection fraction on echocardiogram was abnormal. His blood pressure today was still elevated. Chest pain and hypertension. • Medical Reasoning: Given his recent episode of blood pressure elevation and chest pain, I suspect an element of coronary artery disease as well as pumping dysfunction. • Medical Treatment: We will change his blood pressure regimen to carvedilol 25 mg twice a day. He should also continue lisinopril 10 mg a day and I want to see how his blood pressure does on that regimen. I also recommended cardiac catheterization on him to make sure that he does not have any blockages in his heart. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N012

[doctor] hi , joseph . how are you ? [patient] hey , i'm okay . good to see you . [doctor] good to see you . are you ready to get started ? [patient] yes , i am . [doctor] okay . joseph is a 59 year old male here for routine follow-up of his chronic problems . so , joseph , how have you been doing ? [patient] yeah , i've been kind of managing through my depression , and , uh , my asthma's been acting up 'cause we had a really bad pollen season , and i am at least keeping my diabetes under control , but just , uh , it's just persistent issues all around . [doctor] okay . all right . well , let's start with your diabetes . so , your diet's been good ? [patient] um , for the most part , but we have been traveling all over to different sports tournaments for the kids , so it was , uh , a weekend of , uh , eating on the go , crumby junk food , pizza , and did n't really stick to the diet , so that was a bit of an adjustment . [doctor] okay . all right . um , but , ha- ha- have you ... let's just talk about your review of systems . have you had any dizziness , lightheadedness , fever , chills ? [patient] running up and down the stairs , it was pretty warm , so i did feel a little bit lightheaded , and i did get a little dizzy , but i thought it was just the heat and the fatigue . [doctor] okay . any chest pain , shortness of breath , or belly pain ? [patient] shortness of breath . no belly pain though . [doctor] okay . all right . and , how about any joint pain or muscle aches ? [patient] uh , my knees hurt a little bit from running up and down , and maybe picking up the boxes , but nothing out of the ordinary . [doctor] okay . all right . um , and , in terms of your asthma , you just said that you were short of breath running up and down the stairs , so , um , do , how often have you been using your inhaler over the past year ? [patient] only when it seems to go over about 85 degrees out . that's when i really feel it , so that's when i've been using it . if it's a nice , cool , dry day , i really do n't use the inhaler . [doctor] okay . and , um- [doctor] and , in terms of your activities of daily living , are you able to exercise or anything like- [patient] yes , i do exercise in the morning . i , i ride , uh , our bike for probably about 45 minutes or so . [doctor] okay . all right . and then , your depression , you said it's ... how's that going ? i know we have you on the , on the prozac 20mg a day . are you taking that ? are you having a lot of side effects from that ? [patient] i was taking it regularly , but i've kind of weened myself off of it . i thought i felt a little bit better , but i think , uh , i , i kinda go through battles with depression every so often . [doctor] okay . all right . are you interested in resuming the medication , or would you like to try a different one ? [patient] i , maybe adjusting what i'm currently taking , maybe l- less of a dose so i do n't feel the side effects as much , but i , i'm willing to try something different . [doctor] okay . all right . okay , well , let's , let's go ahead and we'll do a quick physical exam . so , looking at you , you're in , in no apparent distress . i'm feeling your neck . there's no cervical lymphadenopathy . your thyroid seems not enlarged . and , listening to your lungs , you do have some bilateral expiratory wheezing that's very faint , and your heart is a regular rate and rhythm . your abdomen is soft , and uh , your lower extremities have no edema . so , let's go ahead and look at some of your results . hey , dragon , show me the pfts . [doctor] okay , so your , your pfts , that , those are your breathing studies , and those look quite good , so i know that you're wheezing right now , but , um , you know , i think that we can add , add , um , a regimen to that to help , to help you with your , um , exacerbations during the , the summer months , okay ? [patient] okay . [doctor] and then , let's look at your ... hey , dragon ? show me the hemoglobin a1c . okay , so your a1c , you're right , you know , over the past couple months is , you know , your blood sugar's probably been running a little high , so , you know , i know that you're gon na get back on your diet regimen , but , um , for right now , let's go ahead and we'll increase your metformin , okay ? [patient] okay . [doctor] um , and then , hey , dragon ? show me the chest x-ray . okay , good , and your chest x-ray looks fine , so we know that there's no pneumonia there . [patient] mm-hmm . [doctor] and , it's just is all just from your asthma . so , you know , my impression of you at this time , you know , from a diabetes standpoint , let's , let's increase the metformin to 1,000 mg twice a day . um , and , we will get a repeat hemoglobin a1c in three months , and i want you to continue to monitor your blood sugars at home . [doctor] from an asthma standpoint , let's continue you on the albuterol , two puffs , uh , every four to six hours as needed , and we'll add symbicort , two puffs twice a day during the summer , to kind of help prevent those exacerbations . and then , from a depression standpoint , we'll go ahead and start you on a different medication , zoloft , um , 25 mg once a day and see how you tolerate that . does that sound okay ? [patient] perfect . [doctor] all right . so , the nurse will be in soon , and she'll get you situated with all of that , okay ? [patient] great . [doctor] it was good to see you . [patient] same here . [doctor] hey , dragon ? finalize the note .

HISTORY OF PRESENT ILLNESS Mr. Fisher is a 59-year-old male who presents for routine follow up of his chronic problems. Mr. Fisher reports that he has been managing his depression. He is on Prozac 20 mg daily and was taking it regularly, but weaned himself off of it and felt a little better. He is currently taking less of a dose and does not feel the side effects as much, but he is willing to try something different. His asthma has been acting up because of the bad pollen season and has been using his inhaler when it seems to go over 85 degrees. He does not use it if it is cold outside. He is keeping his diabetes under control. The patient 's diet has been good for the most part, but has been traveling all over for his children's sports tournaments and did not stick to his diet and notes over the weekend eating pizza. The patient endorses lightheadedness and dizziness when running up and down the stairs. He attributes this to heat and fatigue. He denies chest pain and abdominal pain. Endorses shortness of breath.. Mr. Fisher also endorses knee pain from running up and down stairs, but nothing out of the ordinary. The patient exercises in the morning and rides a bike for 45 minutes. REVIEW OF SYSTEMS • Constitutional: No fevers, chills. Positive fatigue. • Cardiovascular: Denies chest pain. Endorses dyspnea on exertion. • Respiratory: Positive wheezing. Positive shortness of breath. • Musculoskeletal: Positive joint pain. Deniesswelling, or muscle pain. • Neurological: Positive lightheadedness. Positive dizziness. • Psychiatric: Denies anxiety. PHYSICAL EXAMINATION • Constitutional: in no apparent distress. • Neck: Supple without thyromegaly or lymphadenopathy. • Respiratory: Bilateral expiratory wheezing. • Cardiovascular: Regular rate and rhythm. • Musculoskeletal: No edema in the lower extremities. RESULTS PFT: Within normal limits. Diabetes panel: Glucose and hemoglobin A1c elevated. X-ray of the chest is unremarkable. ASSESSMENT AND PLAN Mr. Joseph Fisher is a 59-year-old male who presents for routine follow up of his chronic problems. Asthma. • Medical Reasoning: His symptoms are exacerbated during warmer weather, but his recent pulmonary function tests were normal. • Medical Treatment: Continue on albuterol, 2 puffs every 4-6 hours as needed. Add Symbicort 2 puffs twice a day during the summer to help prevent exacerbation. Depression. • Medical Reasoning: The patient self-weened from Prozac 20 mg daily due to side effects. • Medical Treatment: We will start him on a different medication, Zoloft 25 mg once a day, to see how he tolerates this. Diabetes Type II. • Medical Reasoning: Recent blood glucose levels and hemoglobin A1c were elevated. • Additional Testing: Repeat hemoglobin A1c in 3 months. Continue to monitor blood glucose levels at home. • Medical Treatment: We will increase metformin to 1000 mg twice a day. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N013

[doctor] hi , john , how are you doing ? [patient] hi , good to see you . [doctor] good to see you too . so i know the nurse told you about dax , i'd like to tell dax a little about you . [patient] sure . [doctor] so john is a 55-year-old male with a past medical history significant for anxiety and epilepsy who presents with an abnormal lab finding . so , john , um , i , uh , was notified by the emergency room that you , um , had a really high blood sugar and you were in there with , uh ... they had to treat you for that , what was going on ? [patient] yeah , we've been going from place to place for different events and we've had a lot of visitors over the last couple of weeks and i just was n't monitoring my sugar intake and , uh , a little too much stress and strain i think over the last couple of weeks . [doctor] okay , yeah , i had gone through your hemoglobin a1c's and you know , they were borderline in the past but- [patient] mm-hmm [doctor] -i guess , you know , i guess they're high now so how are you feeling since then ? [patient] so far so good . [doctor] okay , did they put you on medication ? [patient] uh , they actually did . [doctor] okay , all right . i think they have here metformin ? [patient] yeah , that's- that sounds right . [doctor] all right , um , and , um , in terms of your anxiety , i'm sure that this did n't help much- [patient] did n't help , no , not at all . [doctor] how are you doing with that ? [patient] um , i had my moments but , um , it ... now that it's almost the weekend , it's- it's been a little bit better . i think things are under control by now . [patient] okay . [doctor] okay ? um , how about your epilepsy , any seizures recently ? [patient] not in a while , it's been actually quite a few months and it was something minor but noth- nothing major ever since . [doctor] okay . all right , well you know i wanted to just go ahead and do , um , a quick review of the systems , i know you did a cheat with the nurse- [patient] mm-hmm . [doctor] any chest pain , shortness of breath , nausea , vomiting , dizzy- dizziness ? [patient] no , no . [doctor] okay , any recent fever , chills ? [patient] no . [doctor] okay . and all right , let's go ahead do a quick physical exam . hey , dragon , show me the vitals . so looking here at your vital signs today , um , they look really good . so i'm just gon na go ahead and take a listen to your heart and lungs . [patient] mm-hmm . [doctor] okay , so on physical examination , you know , everything seems to look really good , um lungs are nice and clear , your heart's at a regular rate and rhythm . you do have some trace pitting edema to your lower extremities so what that means is that it looks like you might be retaining a little bit of fluid- [patient] mm-hmm . [doctor] um , did they give you a lot of fluid in the emergency room ? [patient] they actually did . [doctor] okay , all right , so it might just be from that . okay , well let's look at some of your results . hey , dragon , show me the glucose . okay , so yeah , you know i know that they just checked your blood sugar now and it was 162 and you know , what ... you know , did you eat before this ? [patient] uh , probably about two hours ago . [doctor] okay , all right . hey , dragon , show me the diabetes labs . yeah , so your hemoglobin a1c here is is 8 , you know last time we had seen it , it was about 6 and we had n't put you on medications so , um , i think it's something we'll have to talk about , okay ? [patient] you got it . [doctor] um , so let's just talk a little bit about my assessment and my plan for you so for your first problem , this newly diagnosed diabetes . um , you know , i want to continue on the metformin 500 mg twice a day . we'll probably increase that over time . [patient] mm-hmm . [doctor] i'm gon na go ahead and order hemoglobin a1c for the future okay ? [patient] sure . [doctor] um for your second problem , your anxiety . it sounds like you know you might have , you know , some issues leading into the winter . how do you feel about that ? [patient] well , i'll try something new just to help . if it helps that'd be great . [doctor] okay , all right , and so for your last ish issue , your- your epilepsy , you know , i think you saw your neurologist about three months ago , you must be due to see her again some time soon ? [patient] i am . [doctor] and we'll just continue you on the keppra , okay ? [patient] sure . [doctor] any questions ? [patient] not at this point , no . [doctor] okay , um , hey , dragon , finalize the note .

CHIEF COMPLAINT Abnormal labs. HISTORY OF PRESENT ILLNESS John Brooks is a 55-year-old male with a past medical history significant for anxiety and epilepsy, who presents with an abnormal lab finding. The patient was notified by the emergency room physician that he had elevated blood sugar levels. He was started on metformin 500 mg twice daily during that time. He notes that he has going from place to place for different events and they've recently had a lot of visitors; therefore, he was not monitoring his sugar intake over the last few weeks. In terms of his anxiety, he states he has had his moments, but now that it is almost the weekend, his symptoms have improved. Regarding his epilepsy, he has not had any seizures in a few months. He continues to take Keppra. The patient denies chest pain, shortness of breath, vomiting, dizziness, fevers, and chills. REVIEW OF SYSTEMS • Constitutional: Denies fevers, chills. • Cardiovascular: Denies chest pain or dyspnea. • Respiratory: Denies shortness of breath. • Neurological: Endorses epilepsy. • Psychiatric: Endorses anxiety. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Regular rate and rhythm. • Musculoskeletal: Trace pitting edema to the bilateral lower extremities. RESULTS Hemoglobin A1c is elevated at 8. Non-fasting glucose is elevated. ASSESSMENT AND PLAN John Brooks is a 55-year-old male with a past medical history significant for anxiety and epilepsy. He presents today with an abnormal lab finding. Newly diagnosed diabetes. • Medical Reasoning: His past hemoglobin A1c levels have been borderline high, but his most recent level was 8. His blood glucose level is also elevated in clinic today. • Additional Testing: Repeat hemoglobin A1c. • Medical Treatment: Continue metformin 500 mg twice daily. Epilepsy. • Medical Reasoning: He saw his neurologist about 3 months ago and has been asymptomatic for the past few months. • Medical Treatment: Continue Keppra at current dosage. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N014

[doctor] hi , louis . how are you ? [patient] hi . good to see you . [doctor] it's good to see you as well . are you ready to get started ? [patient] yes , i am . [doctor] louis is a 58-year-old male here for follow up from an emergency room visit . so , louis , what happened ? [patient] yeah . i was playing tennis on saturday . it was really , really hot that day , very humid . and about after about a half an hour i was very short of breath , i was struggling breathing . i thought i was having a heart attack , got really nervous . so , my wife took me to the er and , uh , everything checked out , but i was just very upset about it . [doctor] okay . all right . and how have you been feeling since that time ? [patient] uh , foof , probably , probably about six hours after we got home , i felt very light-head and very dizzy and then , sunday , i felt fine . i just thought it was worth checking up with you though . [doctor] okay . and have you been taking all of your meds for your heart failure ? [patient] i have . i have . i've been , uh , very diligent with it . and , uh , i'm in touch with the doctor and so far , so good , other than this episode on saturday . [doctor] okay . and , and you're watching your diet , you're avoiding salt . have you had anything salty ? [patient] i cheat every now and then . you know , i try and stay away from the junk food and the salty foods . but , for the most part , i've been doing a good job of that . [doctor] okay . all right . um , and i know that they removed a cataract from your eye- [patient] mm-hmm . [doctor] . a couple of , like couple months ago . that's been fine ? [patient] that was three months ago , thursday , and everything's been fine ever since . [doctor] okay . so , no vision problems . [patient] no . [doctor] okay . and you had a skin cancer removed about five months ago as well . you've had a lot going on . [patient] yeah . it's been a really busy year . an- and again , so far , so good . that healed up nicely , no problems ever since . [doctor] okay . all right . um , so , why do n't we go ahead and we'll do a quick physical- [patient] mm-hmm . [doctor] . exam . hey , dragon , show me the blood pressure . so , here , your blood pressure is a little high . [patient] mm-hmm . [doctor] um , so , you know , i did see a report in the emergency room that your blood pressure was high there as well . [patient] mm-hmm . [doctor] so , we'll have to just kind of talk about that . uh , but let's go ahead and we'll examine you . [patient] sure . [doctor] okay ? [patient] mm-hmm . [doctor] okay . so , you know , looking at you , your neck is very supple . i do n't appreciate any fibular venous distention . your heart is a regular rate and rhythm , no murmur . your lungs have some fine crackles in them , bilaterally . and you have trace lower extremity edema in both legs . so , what that means , essentially , is that you may have some extra fluid on board , um , from eating salty foods- [patient] mm-hmm . [doctor] . along with this history of your congestive heart failure . but , let's go ahead and look at some of your results . hey , dragon , show me the ecg . so , this is , uh , a s- a stable ecg for you . this basically shows that you have some left ventricular hypertrophy which caused your congestive heart failure . um , let's go ahead and review your echocardiogram . hey , dragon , show me the echocardiogram . so , in reviewing the results of your echocardiogram , it shows that your pumping function of your heart is a little low , uh , but it's stable . and , you know , i think that we know this and we have you on the appropriate- [patient] mm-hmm . [doctor] medication therapy . and then , i just wan na be reminded about , um , the results of your skin biopsy . hey , dragon , show me the skin biopsy results . okay . and in reviewing the pathology report for your skin cancer- [patient] mm-hmm . [doctor] . you know , it looks like they got all of that and everything's fine . [patient] yep . [doctor] so , you know , my impression of you at this time , for the shortness of breath that you had in the emergency department , i think it was an exacerbation of your heart failure . and you probably had some , what we call , dietary indiscretion , you ate some salty food which made you retain some fluid . [patient] mm-hmm . [doctor] so , for that , i'm going to prescribe you , you know , an extra dose of lasix 80 milligrams , once a day . and , um , we're going to , uh , put you on some carvedilol 25 milligrams , twice a day . okay ? [patient] okay . perfect . [doctor] um , and i think from a , a cataract surgery standpoint and your skin cancer removal , everything seems to be fine and you're doing well , so i do n't think we need to adjust any of those medications . [patient] good to hear . [doctor] okay ? hey , dragon , order lasix 80 milligrams , once a day . hey , dragon , order carvedilol 25 milligrams , twice a day . okay . and the nurse will come in and she'll see you soon . okay ? [patient] great . [doctor] hey , dragon , finalize the note .

CHIEF COMPLAINT Follow-up from an emergency room visit. HISTORY OF PRESENT ILLNESS Louis Williams is a 58-year-old male presenting for a follow-up from an emergency room visit. The patient states that he was playing tennis on Saturday, that he was really hot and that after approximately 30 minutes he was struggling to breathe. He states that he thought he was having a heart attack at that time. His wife took him to the emergency room and at that time, he states that he had been feeling very lightheaded and dizzy. He notes that on Sunday he felt fine. The patient reports that he has been very diligent with his medications for his congestive heart failure. He notes that he has been avoiding salt for the most part but there has been some dietary indiscretion more recently. He is status post cataract extraction approximately 3 months ago, and notes that everything has been fine since then. He denies any vision problems at this time. The patient had a skin cancer removed approximately 5 months ago. He reports this is well healed. REVIEW OF SYSTEMS • Cardiovascular: Endorse dyspnea on exertion. • Respiratory: Endorses shortness of breath. • Neurological: Endorses lightheadedness and dizziness. PHYSICAL EXAMINATION • Neck: Supple. No jugular venous distention. • Respiratory: Fine crackles bilaterally. • Cardiovascular: Regular rate and rhythm. No murmurs. Bilateral lower extremity edema. RESULTS ECG revealed left ventricular hypertrophy consistent with congestive heart failure. Echocardiogram demonstrates stable diminished ejection fraction. Skin cancer pathology demonstrates clear margins. ASSESSMENT AND PLAN The patient is a 58-year-old male who presents for follow-up after emergency room visit. ED follow-up and congestive heart failure. • Medical Reasoning: I believe his symptoms which led to his ED visit were due to an exacerbation of his heart failure. He admits to some dietary indiscretion, which likely resulted in fluid retention. • Medical Treatment: I will prescribe Lasix 80 mg once a day. I will also place him on carvedilol 25 mg twice a day. Status post basal cell carcinoma removal. • Medical Reasoning: He seems to be doing well and the removal site is well-healed. No change in treatment is necessary at this time. Status post cataract surgery. • Medical Reasoning: He seems to be doing well. We will continue to observe, but no treatment changes are needed today. Patient Agreements: The patient understands and agrees with the recommended medical treatment.

virtassist

D2N015

[doctor] thanks , rachel . nice , nice to meet you . [patient] yeah . [doctor] um , as my nurse told you , we're using dax . so i'm just gon na tell dax a little bit about you . [patient] mm-hmm . [doctor] so rachel is a 48-year-old female here for shortness of breath . she has a history of depression , smoking , and chronic back pain . so tell me about this shortness of breath . [patient] okay . so there are times when i'm either doing very , very mild exercises or just walking , even if i'm just walking up , you know , my driveway , i find myself palpitating a lot , and there's a little bit of shortness of breath . [doctor] mm-hmm . [patient] i do n't know if it's got to do with the back pain , you know , whether that gets triggered as well at the same time . [doctor] right . [patient] but definitely i feel it happens more often lately . [doctor] okay . and anything else change recently ? like , have you changed lifestyle , like you're exercising more than you used to , having any allergies , anything like that ? [patient] probably exercising more to get rid of the covid 15 . [doctor] the covid 15 . yeah . now last time i saw you , you were smoking two packs a day . how much are you smoking now ? [patient] um , it's gone down quite a bit because , yeah , we said we have to make some , you know , changes as you get older . [doctor] yeah . [patient] so i would say it's probably , um , maybe , maybe a couple ... probably a coup- i do n't know . probably once or day or something . [doctor] just couple cigarettes a day ? [patient] probably once a day , yeah . [doctor] we're getting close . [patient] yeah . [doctor] that's awesome . [patient] mm-hmm . [doctor] that's great news . um , and then how's your depression doing ? [patient] i have my moments . [doctor] yeah . [patient] there are some days when i feel , you know , i wake up and everything was great . [doctor] uh- . [patient] and then there are times , i do n't , i do n't know whether it's got to do with the weather or what else kind of triggers it . [doctor] yeah . [patient] there are some days when i feel extremely low . [doctor] okay . and you had been taking the effexor for your depression . are you still taking that ? [patient] yes , i am . [doctor] okay , great . and then , um the chronic back pain , we've been giving you the gabapentin neurontin for that . is that helping control the pain ? [patient] i think it is . [doctor] yeah . [patient] it is ... it's definitely , um , i feel better . [doctor] uh- . [patient] but it does come every now and then . [doctor] right . what do you do when it's really bad ? [patient] um , i try to just get as much rest as i can . [doctor] okay . and you had talked about doing yoga . are you doing yoga anymore ? [patient] i wish i said yes , but i have n't really made it a habit . [doctor] okay . okay . well , um , you know , said ... you said you were coming in with shortness of breath , so we sent you to get some pulmonary function tests . [patient] mm-hmm . [doctor] so let's just look at those . hey , dragon , show me the pulmonary function tests . okay , so it looks like ... , it's interesting . it says that you might be having a little bit of asthma or , uh , copd . and if you are , we'll talk about that . [patient] mm-hmm . [doctor] let's look at our x-ray . hey , dragon , show me the most recent x-ray . okay , i said it wrong . hey , dragon , show me the most recent chest x-ray . okay , this is interesting . your ... kind of your diaphragm is a little bit flatter , and we'll see that in some , uh , copd , which happens with smokers often . so let's just do a quick physical exam . i know my nurse did the review of systems with you . is there anything else bothering you that we need to talk about today ? [patient] no other issues . [doctor] okay . great . let's do the exam . all right , so your physical exam looks pretty normal other than you've got kind of these mild wheezes in all your lung fields . and so i think you do have copd from your pulmonary function tests , your x-ray , and that . so i'm gon na diagnose you with copd . chronic obstructive pulmonary disease . it means you're not able to exhale appropriately . [patient] mm-hmm . [doctor] so we're gon na put you on a medicine called combivent . okay , you're gon na do two puffs twice a day . it's gon na help open up your lungs . it's an inhaler . [patient] mm-hmm . [doctor] i'm also gon na prescribe albuterol , which you use when you get really short of breath . it's like a rescue thing . [patient] mm-hmm . [doctor] um , and then i'm gon na prescribe some steroids to help , also some prednisone . so let me just order those . [patient] okay . [doctor] hey , dragon , order combivent , uh , two puffs twice a day . order albuterol , two puffs as needed . and order , uh , prednisone uh taper pack . okay , so and then it sounds like your depression's stable , so we're not gon na change anything . you're gon na keep taking the effexor . um , do yoga for depression and your back pain , so for your back pain , stay on the neurontin , and we just wo n't do anything different . any questions for me . [patient] no , i think this is good . thank you . [doctor] perfect . hey , dragon , finalize the note . why do n't you ...

CHIEF COMPLAINT Shortness of breath. HISTORY OF PRESENT ILLNESS The patient is a 48-year-old female who presents for shortness of breath. She has a history of depression, smoking and chronic back pain. The patient reports shortness of breath with mild exercise and walking. She also notes some palpitations at times. She is not sure if it is due to her back pain or not. The patient states she has been exercising more. She continues to smoke but has decreased from two packs a day down to a couple of cigarettes daily. Regarding her depression, the patient feels that it is well managed on Effexor. Regarding her chronic back pain, the patient has been taking Neurontin, which she states is helping control her pain. She states she tries to get as much rest as she can. She is no longer doing yoga as she has not made it a habit. REVIEW OF SYSTEMS • Cardiovascular: Endorses dyspnea on exertion. Endorses palpitations. • Respiratory: Endorses shortness of breath. • Musculoskeletal: Endorses back pain. • Integumentary: • Psychiatric: Endorses depression. PHYSICAL EXAMINATION • Respiratory: Mild wheezes bilaterally. RESULTS Pulmonary function test demonstrates mild asthma and the appearance of COPD. X-ray of the chest demonstrates flattening of the diaphragm which is consistent with COPD. ASSESSMENT AND PLAN COPD. • Medical Reasoning: The patient presents today with shortness of breath with exertion. Her pulmonary function tests suggest asthma or COPD and her most recent chest x-ray and physical examination today are also consistent with COPD. • Patient Education and Counseling: I counseled the patient on the importance of smoking cessation. • Medical Treatment: We will start the patient on Combivent, 2 puffs twice a day. I will also prescribe an albuterol inhaler, 2 puffs as needed, and a prednisone taper pack. Depression. • Medical Reasoning: It sounds like her depression is stable, so we will not change anything at this time. • Patient Education and Counseling: She will keep taking the Effexor. I encouraged her to practice yoga for depression relief as well as her back pain. Chronic back pain. • Medical Reasoning: The patient says she is doing well on Neurontin with only occasional exacerbation of the pain. • Medical Treatment: She can continue Neurontin as is. I also encouraged her to practice yoga for her back pain. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N016

[doctor] hi , edward , how are you ? [patient] i'm doing well , yourself ? [doctor] i'm doing okay . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] absolutely . [doctor] edward is a 59 year old male with a past medical history significant for depression , hypertension and prior rotator cuff repair who presents for followup of his chronic problems . so , edward , it's been a little while since i saw you . [patient] mm-hmm . [doctor] how are you doing ? [patient] i'm doing pretty well , actually . it's been a good , uh , good six months . [doctor] good . okay . so , you know , the last time we spoke , you know , you were trying to think of some new strategies to manage your depression . you did n't wan na go on medication because you're already on a bunch of meds . [patient] absolutely . [doctor] so , how are you doing with that ? [patient] i'm doing well . i see a counselor , uh , once a week . uh , and i've been out swimming at the pool a lot this , this , uh , summer , and , uh , fall . so , things have been well , going well with my depression . [doctor] okay , so , you do n't wan na , you do n't feel the need to start any medications at this time ? [patient] no , no , no . but , i know i can call you if i do . [doctor] yeah , absolutely . [patient] okay . [doctor] yeah . all right . and then , in terms of your high blood pressure , how are you doing with that ? i know we , we were kind of struggling with it la- six months ago . how are you doing ? [patient] i still have my good days and my bad days . i do take my medicine daily . uh , but , you know that burger and wine , every once in a while , sneaks in there , and that salt be ... we know what that does . [doctor] yeah . so , i love burgers and wine too . [patient] okay . [doctor] so , i get it . um , okay , so , and you're taking the norvasc ? [patient] norvasc , yep . [doctor] okay . um , and , you're checking your blood pressures at home , it sounds like ? [patient] i , i do . well , i go to cvs pharmacy . they , they have a , uh , machine that i can sit down at quickly and get my , uh , blood pressure taken . and , i go there about once a week . [doctor] okay . all right . and then , i know that you had that rotator cuff repaired about eight months ago . how are you doing ? [patient] um , it's doing well . i , i'm , i'm , been stretching with a yoga ball . [doctor] uh- . [patient] and , uh , i'm getting stronger each time . and , i can continue that once a week also . [doctor] okay . are you still seeing the physical therapist in the center , or are you just doing exercises at home ? [patient] i'm just , i progressed to exercises at home . [doctor] okay . all right . great . all right . well , i know you did a review of systems sheet when you checked in . [patient] mm-hmm . [doctor] and , you know , it seems like you're doing well . any symptoms at all ? any nasal congestion or chest pain , shortness of breath , anything ? [patient] no . none of those . i do , do notice that i get a little bit of a de- , uh , swelling in my ankles . [doctor] okay . [patient] uh , mainly near the end of the day . [doctor] okay . [patient] um , it seems to go away by the next morning . [doctor] okay . all right . all right . maybe that has to do with some of the salt intake you're , you're eating . [patient] okay . [doctor] all right . well , i wan na go ahead and do a quick physical exam , okay ? [patient] mm-hmm . [doctor] hey , dragon ? show me the blood pressure . yeah , so , your blood pressure's a little elevated today , 156 over 94 . [patient] okay . [doctor] you know , you could be a little happy to see me . i do n't know . [doctor] um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months . [patient] okay . [doctor] so , we'll have to just kinda talk about that , okay ? [patient] okay . [doctor] i'm gon na go ahead and listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] okay . [doctor] okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past . [patient] okay . [doctor] so , that seems stable to me . um , on your lung exam , everything sounds nice and clear , and on your lower extremity exam , i do appreciate , you know , 1 to 2+ pitting edema in your legs , okay ? so , we'll have to just talk a little bit about your diet and decreasing the salt intake , okay ? [patient] okay . [doctor] so , let me just look at some of your results , okay ? hey , dragon ? show me the labs . so , looking here at your lab results , everything looks really good . you know , your creatinine , that's your kidney function , that looks stable . everything looks good from that standpoint . hey , dragon ? show me the ekg . and , looking here at your ekg , everything , you know , looks fine . there's no evidence of any coronary artery disease . it's a nice , normal ekg , which is good . [patient] okay . [doctor] okay ? [patient] good . [doctor] so , let me just talk a little bit about my assessment and my plan for you . okay ? so , from a depression standpoint , it's , you know , your first problem , i think that that sounds like you're doing really well managing it . you know , you have good strategies . it sounds like you have a good support system , um , and i agree . i do n't think you need to start on any medication at this time , but you said before , you know you can call me , okay ? [patient] yes . [doctor] for your second problem , your hypertension , i , i do n't believe it's well controlled at this time . so , i wan na go ahead and , you know , increase the norvasc up to 10 mg a day , and i wan na go ahead and order an echocardiogram and a lipid panel , okay ? [patient] okay . [doctor] hey , dragon ? order an echocardiogram . and , for your third problem , your rotator cuff repair , i , i think you're doing really well with that . i would just continue with the exercises and , uh , i do n't think we need to intervene upon that anymore . it sounds like that's pretty much resolved , okay ? [patient] good . good . [doctor] do you have any questions about anything ? [patient] no questions . [doctor] okay , great . hey , dragon ? finalize the note .

CHIEF COMPLAINT Follow-up of chronic problems. HISTORY OF PRESENT ILLNESS Edward Butler is a 59-year-old male with a past medical history significant for depression, hypertension, and prior rotator cuff repair. He presents for a follow-up of his chronic problems. Regarding his depression, he has been doing pretty well over the last 6 months. The patient notes that he sees a counselor once a week. He states that he has been swimming at the pool a lot this summer and fall. The patient has preferred to avoid medications to treat this. Regarding his hypertension, he states that he has good days and bad days. He adds that he takes his Norvasc daily. The patient states that he checks his blood pressure at CVS about once weekly. He does admit to occasionally drinking wine and eating burgers. The patient had his rotator cuff repaired about 8 months ago. He states that he is doing well. He states that he is no longer seeing a physical therapist in this center, however, he is progressing to exercises at home. The patient notes that he stretches with a yoga ball and is getting stronger. He notes that he experiences mild swelling in his ankles, mainly near the end of the day. He states that the swelling resolves by the next morning. The patient denies nasal congestion, chest pain, or shortness of breath. REVIEW OF SYSTEMS • Ears, Nose, Mouth and Throat: Denies nasal congestion. • Cardiovascular: Denies chest pain or dyspnea on exertion. • Respiratory: Denies shortness of breath • Musculoskeletal: Bilateral ankle swelling. • Psychiatric: Endorses depression. PHYSICAL EXAMINATION • Neurological/Psychological: Appropriate mood and affect. • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Slight 3/6 systolic ejection murmur, stable. • Musculoskeletal: 1-2+ pitting edema in the bilateral lower extremities. VITALS REVIEWED • Blood Pressure: Elevated at 156/94 mmHg. RESULTS Labs: Creatinine is within normal limits. Electrocardiogram is normal. No evidence of coronary artery disease. ASSESSMENT AND PLAN Edward Butler is a 59-year-old male with a past medical history significant for depression, hypertension, and prior rotator cuff repair. He presents for a follow-up of his chronic problems. Depression. • Medical Reasoning: He is doing well with therapy and physical activity. He continues to decline medication for this. • Medical Treatment: Continue current management strategies. • Patient Education and Counseling: I encouraged him to contact me should he want to try medication. Hypertension. • Medical Reasoning: This is uncontrolled at this time. He is compliant with Norvasc, but admits to occasional dietary indiscretion. • Additional Testing: We will order a lipid panel and an echocardiogram. • Medical Treatment: Increase Norvasc to 10 mg daily. 8 months status post rotator cuff repair. • Medical Reasoning: He is doing well postoperatively. He has progressed from formal physical therapy to solely home exercise. • Medical Treatment: Continue with home exercise. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtassist

D2N017

[doctor] hello , mrs . peterson . [patient] hi , doctor taylor . good to see you . [doctor] you're here for your hip today , or your- your leg today ? [patient] yes . i hurt my- the- my- top part of my right leg here . [doctor] hey , dragon . i'm seeing mrs . peterson , here , she's a 43-year-old patient . she's here for left leg pain . right leg pain , right leg pain ? [patient] yes . [doctor] um so , what happened to you ? [patient] i was bowling and as i was running up to the lane , i had my bowling ball all the way back , and when i slung it forward , i hit it right into my leg instead of the lane and so then i fell but- yeah- [doctor] did you get a strike ? [patient] no . in fact , i actually dropped the ball and it jumped two lanes over and landed in the other people's gutter . [doctor] terrific , terrific . so , did it swell up on you ? [patient] it- not- did n't seem like it swelled that much . [doctor] what about bruising ? [patient] um , a little bit on the back- back end , that side . [doctor] have- have you been able to walk on it ? [patient] just a little bit . very carefully . [doctor] sore to walk on ? [patient] yes . it's very sore . [doctor] um , and going upstairs or downstairs , does that bother you at all ? [patient] yeah , well , i do n't have stairs , but um , i would avoid that at all costs . [doctor] okay . um , it looks like you had a history of atopic eczema in your past ? [patient] yes . yes , i have eczema . [doctor] okay . and you take uh- uh , fluocinonide for that ? [patient] yes , when it gets really itchy , i'll- i'll use that and it usually takes care of it . [doctor] okay . and , it looks like you have a pre- previous surgical history of a colectomy ? what happened there ? [patient] yes , i had a- um , some diverticulosis and then um , i actually went into diverticulitis and they ended up going in and having to remove a little bit of my colon . [doctor] okay , let me examine you . does it hurt when i push on your leg like that ? [patient] yes , it does . [doctor] okay . if i lift your leg up like this , does that hurt ? [patient] no . [doctor] so , on my exam , you have some significant tenderness to the lateral aspect of your um right upper leg . you do n't seem to have any pain or tenderness with flexion or extension of your um your lower leg . um , are you taking anything for it right now ? [patient] i've been going back and forth between taking ibuprofen and tylenol . [doctor] okay . well , my impression is that you- you probably have a contusion , but let's take a look at your x-ray first . hey , dragon . show me the x-ray . yeah , so if you look at this , this is a normal femur . um , really do n't see any evidence of a fracture or any swelling , so it's essentially , a normal x-ray . so , what we're going to do is , i'm going to start you on um an anti-inflammatory . it's going to be mobic 15 milligrams uh , once a day . i want you to use some ice for the pain , um , and it should , honestly , just being a contusion , get better in the next week or so . if it's not getting better , of course , come on back and- and see me . [patient] okay , sounds good . [doctor] hey , dragon . go ahead and um , pres- do the orders and um , procedures uh , as described . come with me , and uh , i'll get you checked out . dragon , go ahead and finish off the note .

CC: Right leg pain. HPI: Ms. Peterson is a 43-year-old female who presents today for an evaluation of right leg pain. She states she was bowling and hit her leg with the ball and fell. She developed mild bruising. She denies swelling. She has been walking very carefully. She is alternating Tylenol and ibuprofen. She has a history of atopic eczema and takes Fluocinonide topical cream for it. She has a history of colectomy following diverticulosis. EXAM Examination of the right leg shows significant tenderness to the lateral aspect of the right upper leg. No pain or tenderness with flexion or extension of the lower leg. RESULTS X-rays of the right lower extremity is normal, no fractures or dislocations. IMPRESSION Right leg contusion. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended Mobic 15 mg once a day. She will use ice for pain. She will follow up as needed.

virtassist

D2N018

[doctor] hi miss russell . [patient] hi- [doctor] nice to meet you- [patient] doctor gutierrez . how are you ? [doctor] i'm well . [patient] good . [doctor] hey dragon . i'm seeing miss russell . she's a 39-year-old female here for , what are you here for ? [patient] it's my right upper arm . it hurts really , really bad . [doctor] so severe right upper arm pain . [patient] yeah , uh yes . [doctor] and how did this happen ? [patient] i was playing volleyball yesterday , uh last night . um and i went to spike the ball , and the team we were playing , they're dirty . so um , somebody right across from me kinda kicked my legs from under me as i was going up , and i fell and landed on my arm . [doctor] mm-hmm , like right on your shoulder . [patient] yeah . [doctor] ow . [patient] yes . [doctor] that sounds like it hurt . [patient] it was nasty . [doctor] um , so this happened , what ? like 12 hours ago now ? [patient] uh , seven o'clock last night , so a little more than that . [doctor] okay . [patient] eighteen hours . [doctor] so less than a day . [patient] yeah . [doctor] in severe pain . [patient] yes . [doctor] have you taken anything for the pain ? [patient] i've been taking ibuprofen every six hours i think , but it's really not helping at all . [doctor] okay , what would you rate your pain ? [patient] it's like a nine . [doctor] nine out of 10 ? [patient] yeah . [doctor] so like really severe ? [patient] yes . [doctor] have you used any ice ? [patient] no , i have n't . [doctor] okay . and do you have any medical problems ? [patient] i have gallstones . [doctor] okay . do you take any medicine for it ? [patient] pepcid . [doctor] okay . and any surgeries in the past ? [patient] yes , i had a lumbar fusion about six years ago . [doctor] okay . [patient] um , yeah . [doctor] all right . let's uh , let's look at your x-ray . [doctor] hey dragon . show me the last radiograph . so this is looking at your right arm , and what i see is a proximal humerus fracture . so you kinda think of your humerus as a snow cone , and you knocked the- [patient] the top of the snow cone ? [doctor] the top off the snow cone . um , so i'll be gentle but i want to examine your arm . [patient] all right . [doctor] okay . [patient] all right . all right . [doctor] all right . are you able to straighten your arm ? [patient] yeah , i can just straighten the elbow as long as i do n't move up here . [doctor] as long as you do n't move your shoulder . [patient] yeah . [doctor] go ahead and bend . okay . so your exam is generally normal , meaning that the rest of your body is normal [patient] [doctor] but you've got some swelling and erythema- [patient] yeah . [doctor] . on that right shoulder . you've got uh , tenderness over your right shoulder . you've got normal pulses , and everything else is normal . any numbness or tingling in that right arm ? [patient] no . [doctor] okay . um , so what we're going to have to do- the good thing about um , these kinds of fractures is generally , they will heal up without surgery . um , but we have to put you in a sling that weighs your arm down and pulls it down . so we're going to put you in a long arm cast and a sling , and then we're gon na check you in two weeks to see if those bones have realigned and if they have n't , then we're gon na have to talk about doing surgery at that time . [patient] okay . [doctor] i'm going to prescribe you some pain medicine . we'll do lortab 500- lortab 5 milligram . [doctor] um , you can take one to two tablets every uh , six hours as needed for pain . i'll give you 20 of those . [patient] all right . [doctor] and um , do you have any allergies to medicines ? i did n't ask . [patient] no , i do n't have no allergies . [doctor] okay . um , hey dragon , go ahead and order any medications or procedures discussed . um , do you have any questions for me ? [patient] no , i do n't . [doctor] okay , great . why do n't you come with me , we'll get the tech to put the cast on . [patient] okay . [doctor] and we'll get you checked out . [patient] thank you . [doctor] hey dragon , finalize the report .

CC: Right upper arm pain. HPI: Ms. Russell is a 39-year-old female who presents today for an evaluation of severe right upper arm pain. She states she was playing volleyball yesterday and fell and landed on her arm. She has been taking ibuprofen every 6 hours but it does not help. She rates her pain 9/10. She denies any numbness or tingling in her arm. She has a history of gallstones and takes Pepcid. She has a past surgical history of a lumbar fusion 6 years ago. She denies any allergies. EXAM Examination of the right upper extremity shows swelling and erythema of the right shoulder. Tenderness over the right shoulder. Normal pulses. RESULTS X-rays of the right humerus, 2 views, obtained on today's visit show a proximal humerus fracture. IMPRESSION Right proximal humerus fracture. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended we place her into a long arm cast and sling. She will follow up in 2 weeks for repeat imaging. At that point, we may need to discuss surigical options. I will prescribe Lortab, 5 mg, #20 (twenty) to take every 6 hours as needed for pain. All questions were answered.

virtassist

D2N019

[doctor] hi ms. hernandez , dr. fisher , how are you ? [patient] hi dr. fisher . i'm doing okay except for my elbow here . [doctor] all right . so it's your right elbow ? [patient] it's my right elbow , yes . [doctor] okay . hey dragon , ms. hernandez is a 48-year-old female here for a right elbow . so , tell me what happened . [patient] well , i was , um , moving to a new home- [doctor] okay . [patient] and i was , um , moving boxes from the truck into the house and i lifted a box up and then i felt like this popping- [doctor] hmm . [patient] and this strain as i was lifting it up onto the shelf . [doctor] okay . and when- when did this happen ? [patient] this was just yesterday . [doctor] all right . and have you tried anything for it ? i mean ... [patient] i put ice on it . and i've been taking ibuprofen , but it still hurts at lot . [doctor] okay , what makes it better or worse ? [patient] the ice , when i have it on , is better . [doctor] okay . [patient] but , um , as soon as , you know , i take it off then it starts throbbing and hurting again . [doctor] all right . uh , let's review your past medical history . uh ... looks like you've got a history of anaphylaxis , is that correct ? [patient] yes . yes , i do . yeah . [doctor] do you take any medications for it ? [patient] um , ep- ... just an epipen . [doctor] just epipen for anaphylaxis when you need it . um , and what surgeries have you had before ? [patient] yeah , so carotid . yeah- [doctor] . yeah , no , uh , your , uh , neck surgery . all right . well let's , uh , examine you here for a second . so it's your , uh , this elbow right here ? [patient] yeah . [doctor] and is it hurt- ... tender right around that area ? [patient] yes , it is . [doctor] okay . can you flex it or can you bend it ? [patient] it hurts when i do that , yeah . [doctor] all right . and go ahead and straighten out as much as you can . [patient] that's about it . [doctor] all right . [patient] yeah . [doctor] so there's some swelling there . and how about , uh , can you move your fingers okay ? does that hurt ? [patient] no , that's fine . [doctor] how about right over here ? [patient] uh , no that's fine . yeah . [doctor] okay . so on exam you've got some tenderness over your lateral epicondyle . uh , you have some swelling there and some redness . uh , you have some pain with flexion , extension of your elbow as well . uh , and you have some pain on the dorsal aspect of your- of your forearm as well . okay ? so let's look at your x-rays . hey dragon , show me the x-rays . all right . your x-ray of your elbow- it looks like , i mean , the bones are lined up properly . there's no fracture- [doctor] . it , uh , there's a little bit of swelling there on the lateral elbow but i do n't see any fracture , so that's good . so , looking at the x-ray and looking at your exam , uh , my diagnosis here would be lateral epicondylitis , and this is basically inflammation of this area where this tendon in- inserts . and probably that happened when you were moving those boxes . so we'll try some motrin , uh , about 800 milligrams every six hours . uh , i'll give you a sling for comfort , just so you can use it if- if it's causing a lot of pain . [patient] hmm . [doctor] and it should get better , uh , in about , you know , in a couple of days it should be improved . and if it does n't get better , give us a call and we'll see you some time next week . okay ? so we'll give you a sling , we'll give you the motrin , i'll give you about , uh , 30 , uh , uh , 30 , uh , uh , medications for that . uh , do you have any questions ? [patient] no , no . thank you . [doctor] hey dragon , order the medications and the procedures . all right , why do n't you come with me and we'll get you signed out ? [patient] okay , sounds good . [doctor] hey dragon , finalize the report .

CC: Right elbow pain. HPI: Ms. Hernandez is a 48-year-old female who presents today for an evaluation of right elbow pain. She states she was moving boxes from the truck into the house yesterday and felt a pop in her elbow. She has tried applying ice and taking Ibuprofen, but it does not help. She has a history of anaphylaxis and has an EpiPen. Her past surgical history is significant for neck surgery. EXAM Examination of the right elbow shows tenderness over the lateral epicondyle. Swelling and redness are noted. Pain with flexion and extension of the elbow. Pain over the dorsal aspect of the forearm. RESULTS X-rays of the right elbow shows no obvious signs of acute fracture. Mild effusion about the lateral aspect. IMPRESSION Right elbow lateral epicondylitis. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a sling for comfort. We discussed ice and anti-inflammatory medications. I will prescribe Motrin, 800 mg to take every 6 hours. She will follow up with me as needed if she continues to have pain. All questions were answered.

virtassist

D2N020

[doctor] hi , vincent . how are you ? [patient] i'm good . how about you ? [doctor] i'm good . so le- are you ready to get started ? [patient] i am . [doctor] okay . vincent is a 56-year-old male here with abnormal lab findings . so , i've heard you were in the er , vincent , and they found that you had a low hemoglobin . [patient] yup . [doctor] were you having some dizziness and some lightheadedness ? [patient] i was very lightheaded . i- i do n't know . very lightheaded . [doctor] okay . and have you noticed bleeding from anywhere ? [patient] i have not . i have n't hurt myself in quite a while . maybe a slight nick from a knife while chopping some onions , but nothing more than that . [doctor] but no blood in your stools or- [patient] no . [doctor] . anything like that ? [patient] no . [doctor] okay . and any type of weight loss or decreased appetite or night sweats ? coughs ? [patient] uh , s- slightly decreased appetite , but i wish i had some weight loss . [doctor] um , okay . and how about any abdominal pain ? fever , chills ? [patient] uh , none of that . [doctor] okay . all right . um , any nausea or vomiting ? [patient] not really . yeah . maybe a bit of nausea . [doctor] okay . [patient] i- sitting at the back of a car , that makes me nauseous at times . [doctor] okay . all right . um , well , how are you doing in terms of your knee replacement . i know you had that done last year . that's going okay ? [patient] mm , it seems okay . yeah . [doctor] okay . you're walking around without a problem ? [patient] yup , yup . just not good enough to run yet , but everything else works just fine . [doctor] all right . um , and i know a few years ago , you had , had that scare with the possible lung cancer , but then they did the biopsy and , and you've been fine . [patient] yup , yup . all good . [doctor] turned out to be benign . [patient] yup . [doctor] okay . great . all right . well , let's go ahead and do a quick physical exam . so looking at you , you do n't appear in any distress . your heart is regular . your lungs sound nice and clear . you have some tenderness to the right lower quadrant to palpation of your abdomen . your lower extremities have no edema . [doctor] um , all right . well , let's go ahead and look at your labs , okay ? [patient] yup . [doctor] hey , dragon , show me the hemoglobin . yeah , so your hemoglobin is 8.2 , which is quite low for somebody of your height and weight , so we'll have to look into that a , a little bit further . i know that they did the endoscopy in the emergency room . hey , dragon , show me the endoscope results . [doctor] good . so it looks like you had some gastritis , which is just inflammation of your stomach and they also found a slight polyp , which i know that they biopsied and the results are pending at this time . um , so , you may have had some bleeding from the gastritis . it's not usual for people to have bleeding from that . [doctor] um , okay , well , hey , dragon , show me the anemia panel . okay . [doctor] anyway , okay . well , vincent , i think , you know , in terms of , my impression of you is that you've had this newfound anemia and for that , i think that we should go ahead and put you on protonix , 40 milligrams , once a day to help with the gastritis . does that sound okay to you ? [patient] it does . you're the doctor . i do n't know what it is . [doctor] so that's just , uh , what we call a proton pump inhibitor which , uh , helps decrease the amount of acid secreted within your stomach . [patient] got it . makes sense . [doctor] hey , hey , dragon , order protonix , 40 milligrams , once a day . [doctor] and i'd like you to try to cut down on your caffeine 'cause that can also irritate your stomach . try not to take any ibuprofen and try to cut down on any alcohol intake , okay ? [patient] yup , yup . the coffee's the hard part . [doctor] yeah . it always is . how about one , one , one eight-ounce cup a day ? okay ? [patient] sure . [doctor] um , and we'll go ahead and we'll see you in a couple weeks , okay ? [patient] sure thing . [doctor] i'm going through , uh , i'll also order another , uh , cbc on you . hey , dragon , order a complete blood count . [doctor] all right . the nurse will be in soon . it's , you know , settle all that . i'll see you soon . [patient] see you . [doctor] hey , dragon , finalize the note .

CHIEF COMPLAINT Abnormal labs. HISTORY OF PRESENT ILLNESS Mr. Vincent Young is a 56-year-old male who presents to the clinic today for evaluation of abnormal labs. The patient was seen in the emergency room where he was found to have low hemoglobin. He notes that he has been very lightheaded. He denies any hematochezia. The patient does note some decrease in appetite. The patient reports some nausea when he is sitting in the back of the car. He denies any abdominal pain, fever, chills, vomiting, or recent weight loss. The patient also denies night sweats, or a cough. The patient notes that he is doing well status post knee arthroplasty. He is walking around without any problems. The patient had a biopsy a few years ago for potential lung cancer, however the nodule was benign. He is doing well. REVIEW OF SYSTEMS • Constitutional: No fevers, chills, or weight loss. • Gastrointestinal: Endorses decreased appetite and mild nausea. Denies hematochezia. • Neurological: Endorse lightheadedness. PHYSICAL EXAMINATION • Constitutional: in no apparent distress. • Neck: Supple without thyromegaly or lymphadenopathy. • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds. • Gastrointestinal: Right lower quadrant tender to palpation. • Musculoskeletal: No lower extremity edema RESULTS Hemoglobin- 8.2, which is low for his height and weight. Endoscopy from the emergency room showed gastritis and a slight polyp. The biopsy results are still pending. ASSESSMENT AND PLAN Vincent Young is a 56-year-old male who presents today for lab review. New found anemia. • Medical Reasoning: His hemoglobin was 8.2, which is low for his height and weight. Endoscopy from the hospital showed gastritis which could be the source of bleeding. The endoscopy also showed a polyp and a polypectomy was performed. The pathology is still pending. • Patient Education and Counseling: I encouraged the patient to reduce his caffeine consumption avoid NSAIDs and alcohol. • Additional Testing: Repeat CBC was ordered. • Medical Treatment: I prescribed Protonix 40 mg once a day for gastritis. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

virtscribe

D2N021

[doctor] next patient is christine hernandez , uh , date of birth is january 13th , 1982 . [doctor] hey , miss christine , how are you doing today ? [patient] i'm good , thanks . how are you ? [doctor] i'm pretty good . so it looks like you've completed the covid vaccine , that's great . [patient] yes , i did . [doctor] anything new since your last visit ? [patient] no , i did all the tests that you had recommended me to take . i have n't been able to take the thyroid medicine , the one that you prescribed , as i'm still taking my old one . um , the price was a little high on the new one . [doctor] okay , so did ... did you try the coupon that i gave you ? [patient] i did not try the coupon , uh , there was a charge of $ 75 . [doctor] okay , well , next time that ... that coupon should help , and it should only be about $ 3 . [patient] okay , um ... i do n't have it , do you happen to have another one you can give me ? [doctor] yep , right here . [patient] wonderful , thank you so much , and ... and then the gel , they are charging me $ 100 for it . so , i do n't know if this is because it's a ... it's wal-mart , or if i should try somewhere else , or ... maybe you know how or where i can get it cheaper . [doctor] yeah , let's try something else , um ... sometimes it can be cheaper if we just prescribe you the individual ingredients of a medication , rather than the , the combined medication itself . [patient] that would be great . [doctor] so , that's clindamycin gel and benzoyl peroxide , uh , maybe by doing them separately , they could be a lot cheaper . so , that we can do . the unithroid , with the discount code , should only be about $ 9 for 90 days . [patient] okay , that would be great . yeah , they were charging me $ 75 , and i just could n't pay that . [doctor] maybe we'll try different pharmacy , as well . [patient] okay . so , do you think that my weight gain could have been the birth control that i was taking before that caused it ? [doctor] maybe . i do n't really see an endocrine cause for it , at least , so i would need to see the , the hyperandrogynism or high testosterone . or , a high dhea , to cause acne , or hair growth , or any of that stuff . but , the numbers are n't showing up out of range . [patient] okay . [doctor] i really do n't see any endocrine cause for it , like i said . your growth hormone was fine , but we definitely want to and need to treat it . um , i do n't know if we talked about maybe a little weight loss study . [patient] you mentioned the weight loss study , and you mentioned that i have some meal plans , um , that you had given me . i still have those , too . [doctor] have you tried to make any changes in the diet since the last time we spoke ? [patient] i've been trying to get better . i will start back at the gym in july , because of my contract , i had to put a hold on it until then . [doctor] okay . [patient] so , i do want to start doing that . i will be a little freer since , um , i'll be on vacation after july 8th . [doctor] okay , good . [patient] and then my cousin was telling me to ask you about cla , because it's supposed to help your metabolism . is that okay to take ? [doctor] um , i'm not sure . what is c , cla ? [patient] i'm not sure what it is , either . [doctor] okay , well , i'm unfamiliar with it , so ... [patient] okay . i also have a coworker who has a thyroid issue too , and she suggested to try chromium for weight loss . [doctor] so , that likely will not help too much . you can try either , if you really want to , but then ... it will not accept you into the weight loss study if you try those two . [patient] okay . [doctor] chromium is just a supplement and it wo n't help that much . [patient] it wo n't , okay , thank you . [doctor] it wo n't hurt ... okay , i should n't say that it wo n't hurt , but , it also wo n't help that much . so , it's up to you . [patient] okay . and so , my cousin also suggested amino acids , and that i might find them in certain foods , i guess , for my workout . [doctor] yeah . amino acids are fine , they wo n't , wo n't really help with weight loss either , but it might help , uh , you replenish , and just kind of , feel hydrated . [patient] okay . are they proteins ? um , my cousin said she had lost some weight , and has been working out every day , but she does n't work , so ... i do n't know . [doctor] yes , amino acids are what make up the protein , which is in any food you eat , with any protein . so , meats , dairy , nuts , any of that sort of thing . [patient] okay , thank you . got it . [doctor] all right . um , are you allergic to any medications ? [patient] no , not that i know of . [doctor] okay . is your s- skin pretty sensitive ? [patient] yes . [doctor] all right . [patient] um , yeah , my size , i will start getting rashes , with different products . [doctor] and have you ever tried clindamycin topical , as an antibiotic for your acne ? [patient] no , i've never tried anything for it . [doctor] okay . we might give you some of that . [patient] okay . and i also want to mention that my feet do swell up a lot . [doctor] okay . i'm ... let me take a look at that for just a moment . um , any constipation ? [patient] yes , i also do have that problem . [doctor] all right . mira- miralax will definitely help with that . [patient] okay , yes , my doctor did also recommend that . [doctor] great . all right , let's do an exam real quick . please have a seat on this table and i'll listen to your lungs and heart . [patient] okay . [doctor] all right , deep breath . all right , again . [patient] okay . [doctor] all right , sounds good . [patient] great . [doctor] let me take a look at your feet and ankles . [patient] okay . [doctor] all right , they look okay right now , certainly let your doctor know about this if it gets any worse or reoccurs . [patient] okay , i will do that . [doctor] now , let's go over your lab work . so , when you took that pill , the dexamethasone test , you passed , which means you do n't have cushing's syndrome . on that test , at least . the salivary cortisol , though , unless you did one wrong ... two of them were completely normal and one was abnormal , so , we might need to repeat that in the future . [patient] okay , that's okay . [doctor] all right , so , your cholesterol was quite high . the total cholesterol was 222 . the good cholesterol was about 44 . the bad was 153 , and it should be less than 100 . the non-hdl was about 178 , and it should be less than 130 . the good cholesterol should be over 50 , and it was 44 . so , your screen for diabetes is ... was fine . you do have a vitamin d deficiency , and , i do n't know if we started the vitamin d yet , or not . [patient] yes , we did . i- i do need to take one today , though . [doctor] okay . so , i also checked a lot of other pituitary hormones , iron levels ... everything else seemed to be pretty good , and in decent range . [patient] okay , that sounds great . so , i wanted to also show you my liver enzymes , um , because i have n't come back since then ... but i was also happy , because one of them was back to normal . [doctor] okay , great . let's see them . [patient] okay . so , the one that's 30 , that was almost 200 not so long ago . [doctor] yeah , your alt was about 128 . [patient] okay , and , and back in october was 254 . [doctor] yeah , this is much better . [patient] okay , great . and then it dropped in january , and then it dropped a little more in march , since i stopped taking the medicine in december . [doctor] okay , that's good . so ... i'm proud of you with the course of your labs , so before i forget , i'm going to , uh , just put your labs into the computer today , and i wo n't be checking your vitamin d level for some time . [patient] okay . so , with the thyroid , and the low vitamin d , does that always happen together ? [doctor] um , i do have a lot of people that have thyroid , thyroid issues and they have vitamin d deficiency . [patient] okay . [doctor] this is what i'm , um , i'm going to do . i'm going to put , print out your prescriptions , so you can shop around at the pharmacies and see if you can find better prices . [patient] okay , that way i can go ask them and try cvs . [doctor] yeah , that sounds like a plan . [patient] okay , good . so , the weight loss study that you mentioned , when does that start ? or , how does that work ? [doctor] so , we are about to start , as we just got approval last week , and we are just waiting on our paperwork so we can get started . [patient] okay , and what's involved with that ? [doctor] so , it'll involve you receiving a medication which has been used for diabetes treatment , and it works mostly in the gut on satiety , or satiety hormones . um , the most common side effects are going to be nausea , vomiting , diarrhea and constipation . they are s- uh , six arms , to the study . one is a placebo , the other ones are a , various as ... various dosages of the medication , excuse me . um , you would receive an injection once a week . also , keep in mind that most of the weight loss medications are not covered by insurance . [patient] okay . [doctor] so , it's a way of getting them , but , the odds of getting one of the arms with the medication that are in your favor , right , might be only one out of five of our hundred patients that we have on the list for the study that will receive the placebo . [patient] okay . [doctor] does that make sense ? [patient] yes , it does . [doctor] so , we do expect pretty big weight loss , because of what we learn in diabetes study . so , it's a year long , uh , process , and it's an injection once a week . you come in weekly for the first four , five weeks , i believe . and then , after that , it's once a month . you do get a stipend for partici- for participating in the study , and parking is validated , and whatever else that you need for the study . [patient] okay , do you know how much the stipend is ? [doctor] um , i will have to double check for you , and , you do n't have to be my patient , you just have to meet the criteria . so the criteria is a bmi greater than 30 , if you do n't have any other medical condition . or , a bmi greater than 27 , if you do have another medical condition , like your cholesterol . um , a bmi greater than 27 would quali- uh , qualify you . [patient] i have a friend who might be interested , and she does have diabetes . [doctor] if she has d- diabetes , then she wo n't qualify . [patient] okay , you ca n't if you ... if you have diabetes , got it . [doctor] correct . yeah , the only thing that , um , they can not have , really , is diabetes . so , either a psychiatric disease , or schizophrenia , bipolar , things like that . [patient] okay . [doctor] but , if they have hypertension , high cholesterol , things like that ... they can definitely sign up . [patient] and they can , okay . thank you for explaining that . [doctor] of course . so , do you want me to try to get you into that study ? or , would you just like to try , me to prescribe something ? it's kind of up to you . [patient] i think i'll just wait for a little bit now . [doctor] all right , sounds good . i'll give you the information for the research , it's just in my office . um , it is a different phone number , though . so then , if you're interested , just call us within a month , because i do n't know how long , uh , the , the wait will be . [patient] okay , will do . [doctor] perfect . so , let me go grab your discount card for the unithroid . um , when you go in to activate it , the instructions are on this card , and then you use your insurance ... then , show them this , and ask how much it'll cost . if it's too expensive , just let me know . [patient] i will . thank you so much for your help on that . [doctor] you're welcome . then , what i did is , i gave you a topical antibiotic , plus i gave you the benzoyl peroxide . so , the peroxide may bleach your sheets , but , you want to make sure to take it and apply it at night , so you do n't have a reaction from the sun during the day . [patient] okay , i can do that . [doctor] but , you do also want to make sure that you do n't mess up your sheets . [patient] okay , sounds good . [doctor] um , so , that's that . and then , let's see how you do on the other medications . i think this will , this will get better . in the meantime , a low-carb diet , avoid alcohol and fatty foods , and low chole- cholesterol foods . [patient] okay . [doctor] and again , once you finish your dose of vitamin d , for the vitamin d deficiency , you're gon na start with the 2000iu daily , so that you're able to maintain those levels . sound good ? [patient] yes , that sounds great . [doctor] i really think your liver enzymes are going to get better once you lose the weight , though . [patient] okay , that would be great . [doctor] since we stopped your birth control , we can try once called phexxi , which is kind of like a spermicide , basically . [patient] okay . [doctor] and you just apply it before intercourse . [patient] okay . [doctor] if you need some , uh , just let me know . [patient] okay , i will . i'll let you know . [doctor] okay , perfect . so , stay put for me now . i'm going to go see if they have discount samples , and bring you that prescription . and then , i'm going to order the labs for next time . [patient] okay , great , thank you so much . [doctor] you're welcome . [doctor] so , under the plan , under abnormal liver enzymes , they have improved since discontinuation of her birth control . under abnormal weight gain , her dexamethasone suppression test was normal . two out of three salivary cortisol tests were normal , not consistent with cushing's , and therefore we're ruling out cushing's . under her hirsutism , her androgen levels were normal . for the acne vulgaris , the epiduo was not covered , so we'll try benzoyl peroxide with clindamycin , and remove the previous information . on the hyperthyroidism , we'll print out her prescriptions . unithroid should be better priced with the discount card , and we'll repeat levels of everything before next visit . thanks .

CHIEF COMPLAINT Hypothyroidism. Abnormal liver enzymes. Abnormal weight gain. Acne vulgaris. HISTORY OF PRESENT ILLNESS Christine Hernandez is a 39-year-old female who presents today for evaluation and management of abnormal liver enzymes and hypothyroidism. When the patient was last seen, her thyroid medicine was changed to Unithroid, but due to the cost of $75, she has not yet started the new medicine and continues taking her previous thyroid medicine. She denies utilizing the coupon that was previously recommended for the Unithroid. Similarly, the patient was prescribed Epiduo for her acne vulgaris, which she did not fill due to the cost of $100. She tried filling both prescriptions at Walmart. Mrs. Hernandez still presents with abnormal weight gain. She questioned if her oral contraceptive Microgestin, which was discontinued, could have been the cause. Additional symptoms included acne, hirsutism. She is attempting to modify her intake and plans to resume her gym membership in July as she will be on vacation. She inquired about the impact on weight loss of chromium, CLA, and amino acids. The patient confirmed that she is taking her high dose Vitamin D as prescribed. She does suffer from constipation and she treats with MiraLAX. She denies previous treatment for her acne vulgaris. She denies ever using clindamycin topical antibiotic. She reports having sensitive skin, developing rashes with various skin products. PAST HISTORY Medical Hypothyroidism. Acne Vulgaris. Vitamin D deficiency. Abnormal weight gain. Hirsutism. Constipation. CURRENT MEDICATIONS Benzoyl Peroxide. Clindamycin Gel applied topically. Vitamin D 2000 IU daily. Unithroid. MiraLAX. ALLERGIES No known allergies. RESULTS Dexamethasone Suppression Test: Normal. Salivary Cortisol Tests: 2 out of 3 were normal. Not consistent with Cushing’s Syndrome. Hepatic Function Panel: ALT 128. Lipid Panel: Total cholesterol 222 mg/dL, HDL 44 mg/dL, LDL 153 mg/dL, non-HDL 178 mg/dL. FAI: Normal. ASSESSMENT • Hypothyroidism. • Abnormal liver enzymes. • Abnormal weight gain. • Acne vulgaris • Vitamin D deficiency. • Hirsutism PLAN Hypothyroidism The patient will again attempt to initiate Unithroid. I have printed out the prescription and a discount card, which should result in a reduced price. She will contact my office if she encounters additional issues. Abnormal liver enzymes We have seen improvement since the discontinuation of Microgestin. I recommended the spermicide Phexxi for alternative birth control. The patient will also continue working on weight loss, which should additionally improve her liver enzymes. Abnormal weight gain Cushing’s Syndrome has been ruled out. I reviewed the weight loss study with the patient, she will call within a month if she is interested in participating. I advised her to follow a low carbohydrate, low cholesterol, abstain from alcohol, and reduce fatty foods diet. Acne vulgaris Epiduo was not covered and too expensive. The patient will try benzoyl peroxide and Clindamycin separately to see if the price improves. Vitamin D deficiency The patient will complete the high dose vitamin D and then should start vitamin D 2000 IU per day to maintain her levels. Hirsutism Her androgen levels were normal. INSTRUCTIONS She will repeat all labs prior to her next visit.

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D2N022

[doctor] this is philip gutierrez , date of birth 1/12/71 . he is a 50-year-old male here for a second opinion regarding the index finger on the right hand . he had a hyperextension injury of that index finger during a motor vehicle accident in march of this year . he was offered an injection of the a1 polyregion , but did not want any steroid because of the reaction to dexamethasone , which causes his heart to race . he was scheduled to see dr. alice davis , which it does n't appear he did . he had an mri of that finger , because there was concern about a capsular strain plus or minus rupture of , quote , " fds tendon , " end quote . he has been seen at point may orthopedics largely by the physical therapy staff and a pr , pa at that institution . [doctor] at that practice , an mri was obtained on 4/24/2021 , which showed just focal soft tissue swelling over the right index mcp joint , partial-thickness tear of the right fds , and fluid consistent with tenosynovitis around the fdp and fds tendons . radial and ulnar collateral ligaments of the index mcp joint were intact , as the mcp joint capsule . extensor tendons also deemed intact . [doctor] his x-rays , four views of the right hand today , show no bony abnormalities , joint congruency throughout all lesser digits on the right hand , no soft tissue shadows of concern , no arthritis . hi , how are you , mr . gutierrez ? [patient] i'm good , how about you ? [doctor] well , how can i help you today ? [patient] so i was a passenger in , uh , a car that was rear-ended , and we were hit multiple times . i felt two bumps , which slung me forward and caused me to stretch out my right index finger . [doctor] so hitting the car in front of you all made that finger go backwards ? [patient] um , i do n't really know . i just felt , like , it felt like i laid on my finger , and so , i felt like it went back , and it's been hurting since about march . and it's been like that ever , ever since the wreck happened . so i , and i ca n't make a fist , but sometimes the pain's unbearable . and , like , even driving hurts . [doctor] okay , so this was march of this year , so maybe about three months ago ? [patient] yeah , and it's still swollen . so i was seeing , uh , an orthopedist , and they sent me to an occupational therapist . and i've been doing therapy with them , and then they sent me to go back and get an mri . so i went and got the mri . uh , then they told me that the mri came back , and it said i had a tear in my finger , but he was n't gon na give me an injection , because the injection was going to make the tear worse . [doctor] mm-hmm . [patient] and then , after he got the mri , he said that i have , uh , a tear in my finger , and that he did n't wan na do surgery , but he would do an injection . then i'm thinking that you told me you would n't do an injection in there , and then the oper- , occupational therapy says it's because of the tear . and then , they do n't want me to keep rubbing the thing , and doing things with my hand . so i feel like i'm not getting medical care , really . [doctor] yeah , i see that . [patient] so i came to see if you could do anything for this hand , because i am right-handed , and i kinda need that hand . [doctor] what do you do for a living ? [patient] uh , i'm an x-ray tech . [doctor] well , um , so do you have any diabetes or rheumatoid arthritis ? [patient] nope . [doctor] uh , do you take any chronic medications of su- , significance ? [patient] uh , i do take a blood pressure pill , and that's it . [doctor] okay , and it looks like you suffer from itching with the methylprednisolone ? [patient] uh , that's correct . [doctor] all right , well , i'm gon na scoot up closer and just take a quick look at your hand . all right , so , lean over here . all right , so on this exam today , we have a very pleasant , cooperative , healthy male , no distress . his heart rate is regular rate , rhythm , 2+ radial pulse , no swelling or bruise , bruising in the palm over the volar surface of his index finger , normal creases , slightly diminished over the pip of the index finger compared to the middle finger . [doctor] his index finger rests in a 10-degree pip-flexed , uh , position . all right , is that uncomfortable to correct that , and is it uncomfortable now here ? [patient] yeah , uh , when you push on it , yeah . [doctor] all right , how about here ? [patient] um , there , it's not . [doctor] okay , not as bad ? [patient] yeah , it feels , uh , a little numb . [doctor] gotcha , all right . bend , bend the tip of this finger . bend it as hard as you can . keep bending . keep bending . all right , straighten it out . all right , and now , bend it for me as best you can . [patient] my goodness . it feels like it's , it's tearing in there . [doctor] okay , okay . well , bend the tip of this finger , and bend it as hard as you can . keep bending . all right , straighten that out , and now , bend it for me as best you can . all right , good . now , bend that finger , and i'm going to pull , put it down like this . and then bend that finger for me . okay , sorry , can you bend it for me ? all right . now , make a fist . great , so relax the finger . all right , so just keep it , keep , when i bend the finger , we're just going to bend that finger where it meets the hand . is that okay there ? [patient] ow , . [doctor] okay , okay . so all the hurt , it seems , is stretching , because you have n't been doing this for so long . so , you know what i mean ? so , um , you're going to have to start really doing that . [patient] well , i've tried . i even bought myself a splint . [doctor] well , but a splint does n't help move you . it actually immobilizes you . [patient] okay . i thought it would straighten it out . [doctor] no , no . so , so you really need to start bending the finger right here for me , as hard as you can , and keep going , going . all right , so , so you're okay . all right , so i would say the following , that there is a partial tear in one of the two flexor tendons . there is the fdp and the fds , and the fds is the least important of the two . so the mri shows that it's the fds , the flexor digitorum superficialis , which is the least important of the two . [patient] okay . [doctor] uh , now , there's two halves of it . so it's a partial tear of one half of a whole tendon . that's not that important , and the other one is just fine . [patient] so the good one is good ? [doctor] yes , correct . so the one that goes all the way to the tip is good . [patient] okay , good . [doctor] yeah , so you know , i think what you have got so much scar tissue and inflammation around the fds tendon blocking excursion of these other tendons , that they ca n't get through to the pulley . [patient] okay , all right . [doctor] so what i would recommend what we try is a cortisone injection , and i would avoid the dexamethasone , because i saw you have a little reaction to that . but we could use the betamethasone , which is a celestone . [patient] i've gotten another , uh , methylprednisolone , and that itched me like crazy . [doctor] did it ? yeah , this one is water-soluble , and i think it's fairly low toxicity , but high benefit , and i think decreasing the pain will encourage you to move that finger . [patient] all right , we'll give it a try . [doctor] good . so , you do the shot , and it's going to take about three to five days before it starts feeling better . and then probably over the next couple of weeks , it'll start feeling even better . [patient] perfect . [doctor] all right , so take advantage of that . you've got ta start moving the finger . you're not going to tear anything or break a bone , uh , because your intensors , extensors are intact . but your collateral ligaments are intact , so you've got a stiff , sore finger . i'm going to try to help as much as i can with this soreness part , and then you have to do all the stiff part . [patient] the lady in occupational therapy tried some maneuvers to straighten the finger out , but it even hurt after i left . the whole thing just swelled up . [doctor] hmm . okay , so it was injured , and you had scar tissue . and then , you had post-traumatic inflammation . and so , this will help some with all of that . it's not going to make it to where your finger is like , , my finger does n't hurt at all , but it will make it to where at least tolerable , to where you can make some gains . and we actually might need to repeat this as well . [patient] will i be able to drive ? i drove myself here today , so ... [doctor] yeah , it may feel a little weird , but it's totally safe for you to drive . [patient] okay , good . [doctor] so for mr . gutierrez , just put that he has a post-traumatic rather severe stenosing tenosynovitis of his right index finger , and the plan is steroid injection today , do a trigger injection , but i'm using a cc of betamethasone . so , mr . gutierrez , do you have , um , therapy scheduled or set up ? [patient] uh , not at the moment . [doctor] all right , well , i mean , you know that you need to move that finger , and i think to the degree that they can help you do that . so i want you to move that finger , finger , but i think it would be , uh , beneficial for you to have an accountability , um , so at least you know to check in with them once a week with somebody . [patient] um , okay . that's kinda why i'm here , for you to tell me what needs to be done , you know ? [doctor] yeah , so i'll write you out , um , an outpatient prescription . i think if you go back to the same people where you were before , i'm hoping that after this injection , you're going to be able to do a whole lot more with them . so let's do outpatient once a week for six weeks , um , and then full active and passive range of motion is the goal with no restrictions . [patient] all right , sounds like a plan . [doctor] all right , well , i will have the nurse set up the injection procedure , and we'll , and i'll be back shortly . [patient] thanks , doc . [doctor] right trigger finger injection template . attempted to inject one cc of celestone with f- , a half a cc of lidocaine . however , the patient had a dramatic and violent painful reaction to the introduction of the needle , with contortions of the hand , and with dangerously withdrawing the hand with concerns for secondary needle stick . needle was withdrawn . the patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath . we attempted a second time for a similar injection using the same technique with one cc of celestone and half a cc of lidocaine . a small parma- , uh , palmar vein bled a scant amount , which was cleaned up and band-aid applied . reassured on multiple occasions that no harm was done to his finger . recommended icing in it this evening , and taking ibuprofen .

CHIEF COMPLAINT Right index finger hyperextension injury. HISTORY OF PRESENT ILLNESS Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion regarding evaluation of the right index finger hyperextension injury sustained during a motor vehicle accident in 03/2021. In summary, the patient was the passenger in a vehicle that was rear-ended. He reports they were hit multiple times as he felt 2 bumps which caused his to sling forward hyperextending his right index finger. He was offered an injection of the A1 pulley region, but he did not want any steroid due to a reaction to dexamethasone that causes his heart to race. The patient was scheduled to see Dr. Alice Davis, but he has not seen his yet. The patient has been seen at Point May Orthopedics, by the physical therapy staff and a physician assistant at that practice. He underwent an MRI of the right index finger because they were concerned about a capsular strain plus or minus a rupture of the "FDS tendon." The patient states that he is unable to make a fist secondary to pain and swelling in the right index finger. He describes a pulling, tearing sensation in the right index finger. The pain is exacerbated by driving. He notes that he has been wearing a right index finger splint. The patient denies any history of diabetes or rheumatoid arthritis. He reports only taking medication for hypertension and denies taking any other chronic medications of significance. He also notes methylprednisolone causes his to itch. Ms. Gutierrez is employed as an x-ray technician. PAST HISTORY Medical Hypertension. SOCIAL HISTORY Employed as x-ray technician. ALLERGIES Methylprednisolone causes itching. Dexamethasone causes palpitations. REVIEW OF SYSTEMS • Musculoskeletal: Right index finger pain. • Endocrine: Denies diabetes. PHYSICAL EXAM Constitutional Very pleasant, healthy appearing, cooperative male in no distress. Neurological Grossly intact. Slightly diminished sensation to light touch over the right PIP joint of the index finger compared to the middle finger. Cardiovascular Regular rate and rhythm. Musculoskeletal Exam of the right hand, there is no swelling or ecchymosis in the palm on the volar surface of his index finger. Normal creases are noted. Index finger rests in a 10 degree PIP joint flexed position with discomfort upon correction. Bilateral extremities 2+ radial pulses. RESULTS X-rays today, 4 views of the right hand, show no bony abnormalities. Joint congruency throughout all lesser digits on the right hand. No soft tissue shadows of concern. No arthritis. MRI of the right index finger performed on 04/24/2021. Independent review of the images shows focal soft tissue swelling over the right index MCP joint, partial-thickness tear of the right FDS, and fluid consistent with tenosynovitis around the FDP and FDS tendons. Radial and ulnar collateral ligaments of the index MCP joint were intact as was the MCP joint capsule. The extensor tendons were also deemed intact. ASSESSMENT • Stenosing tenosynovitis of right index finger. Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion of his right index finger hyperextension injury sustained during a motor vehicle accident in March of this year. The findings of his examination are consistent with rather severe post-traumatic stenosing tenosynovitis. PLAN The patient and I had a lengthy discussion regarding his history, symptoms, and radiographic findings. We discussed the pathophysiology and natural history of stenosing tenosynovitis and the anatomy of the flexor tendons and pulley system in the hand. I explained to the patient that the flexor digitorum superficialis tendon was clearly intact and that He is suffering from post-traumatic inflammation around the flexor digitorum superficialis tendon blocking excursion of the flexor tendons to the A1 pulley. Treatment options were discussed including conservative management with corticosteroid injections and their statistical effectiveness. Surgical correction was also briefly discussed, although I recommend exhausting non-operative measures with a minimum of 2 injections before proceeding with surgery. I recommended a right index trigger finger cortisone injection today, and the patient elected to proceed. I also recommend that the patient report to occupational therapy once a week for the next 6 weeks to work on full active and passive right index finger range of motion with no restrictions. The patient verbalizes understanding with the treatment plan and agrees. All questions were answered to the patient's satisfaction today. PROCEDURE Right index trigger finger injection. The patient understands the risks and benefits and elected to proceed, signed consent obtained. An attempt was made to inject 1.0 cc of Celestone with 0.5 cc of lidocaine. However, the patient had a dramatic and violent painful reaction to the introduction of the needle with contortions of the hand and with dangerously withdrawing the hand with concerns for secondary needle stick. Therefore, the needle was withdrawn. The patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath. We attempted a 2nd time for a similar injection using the same technique with 1.0 cc of Celestone and 0.5 cc of lidocaine. There was a small palmar vein that bled a scant amount, which was cleaned up off the back of the patient's hand. A Band-Aid was applied. He was reassured on multiple occasions that no harm was done to his finger. I recommended icing it this evening and taking ibuprofen. INSTRUCTIONS Occupational therapy as prescribed.