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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.

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D2N023

[doctor] next patient is paul edwards , date of birth is january 15th 1962 . so he's a 59 year old hiv positive gentleman here for hypogonadism . patient was last seen on november 24th 2020 . his notable things are number one , he is on 1 milliliter every 10 days , uh , his levels were less than 300 to begin with . he's on finasteride currently . he also takes cialis daily so he takes all his pills just from me . um , patient's other area of concern is gynecomastia which is ... which we will discuss with him today . his last psa was 0.66 and his last testosterone was greater than 1,500 . [doctor] hey , how are you today ? [patient] all right , how have you been ? [doctor] i'm good . [patient] good , good . [doctor] have you lost some weight or are you at least putting on some muscle ? you look trim . [patient] no , i think i'm pretty much the same as i've always been . [doctor] really ? okay , maybe it's just your black shirt . makes you look thin . [patient] yeah , i guess that's it . [doctor] so health wise , how is everything going ? [patient] good , the testosterone's going well . [doctor] that's great . [patient] uh , it helped me out . i feel good , more vigorous , sleeping well and i think it's having some positive effects . not so much physically because like i said i've- i've been this way my whole life , but i'm seeing some good improvements in my bloodwork . [doctor] okay , well that's good . [patient] so the finasteride i'm only taking half a pill , it's the 5 milligram one . [doctor] yeah , i remember you telling me that . [patient] and cialis , on the days i work out i take 5 milligrams otherwise i take two and a half milligram pills , but , uh , i have been out of it . [doctor] okay . [patient] but overall i'm doing well , i'm actually taking the correct steps to get my life together . [doctor] good . it's always great to hear . well let's take a look . uhm , i'm gon na listen to your heart and lungs . [patient] okay . [doctor] please use my general exam template , all right . just take a few breaths . [patient] okay . [doctor] in and out . [patient] okay . [doctor] all right , everything sounds good , no concerns there . [patient] great . so i wanted to show you something . [doctor] sure . [patient] look at this . [doctor] okay , this is your cholesterol ? [patient] yeah , my cholesterol and triglycerides . uh , i used to have high triglycerides , you see they were 265 milligrams per deciliter , and i took my first dose of the testosterone on the 28th . [doctor] right . [patient] now 5 months later look at my numbers . [doctor] wow , that's remarkable . [patient] is it the test ? it's the only change . [doctor] i do n't know , i have n't honestly seen many guys over the years that have cholesterol problems and this . i mean there's a big correlation between diabetic control and testosterone replacement , meaning those who get good levels of their test see their diabetic control improve . [patient] yeah . [doctor] but i have n't seen a lot of data on the impact on cholesterol . regardless , we will take it . [patient] i agree . i was very impressed with my triglycerides and was just wondering if the test may be what's helping . [doctor] yeah , that's an unbelievable difference . [patient] 145 milligrams per deciliter from 265 milligrams per deciliter is awesome . i also read that it- it's cardioprotective . [doctor] absolutely . [patient] my red blood cell count has increased . [doctor] yeah , i saw that . it's fine though . [patient] stable . [doctor] your psa today is also , uh , is good also . it's , uh , .6 i think . [patient] yeah . , is it ? [doctor] yeah , it was .5 last year and anything under 4 is good . [patient] nice , that's good news . [doctor] so it just needs to be checked every year or so . [patient] so in terms of , uh , estrogen control i've been hearing that indole-3-carbinol , or broccoli extract , supposedly can improve my estrogen levels . have you ever heard of it ? [doctor] yeah , i've heard of it but i have n't had anybody consistently use it . i mean , your levels are fine and we checked your estra- estradiol and it was not elevated , so . [patient] okay . [doctor] i would argue that we could test that in the fall if you want , but we do n't need to do , uh , do any more tests ... any more than test once a year , excuse me . [patient] okay , what about increasing my testosterone to 175 milligrams ? i'm at 140 now . [doctor] well , your levels are high . [patient] are they right now ? [doctor] well , i mean they were last time . [patient] yeah but i just- just injected though , or i had right before that was taken . [doctor] i know . i know you had then , uh , when did you inject this time ? [patient] i figure i'm on my eighth day today . [doctor] okay . [patient] so i'm due to dose on thursday or friday . [doctor] all right . [patient] i have a little med calendar and i put checks and ts on it . that helps me . [doctor] that's a great idea . so look , the biggest issue i've seen , even if your levels today are around 700 , is that your peaks are getting greater than 1,500 , putting you at a higher chance of needing to come off due to blood thickness . and your risk will only astronomically go up the higher the dose that we go on . [patient] okay . [doctor] you look well , your levels are good and you're feeling well . [patient] yeah , i'm feeling good . [doctor] i'm going to be blunt . unfortunately this happens often where you're feeling good but you want to feel really good . i mean , i get it and this is why people get into problems with this stuff , right ? it's like , back in the day when it was n't prescribed by doctors and people would get it at gyms and stuff and they would take huge doses . and then they would have a heart attack at 50 . [patient] yeah , they have to be taking a lot . [doctor] likely they are taking more than testosterone , but still . [patient] and they are taking stuff for a long time . [doctor] true . but right now i would not change your dose . [patient] okay . [doctor] make sense ? [patient] it does , i appreciate the discussion . [doctor] no problem . what pharmacy are you using ? have you changed it or anything ? [patient] no changes , i use walmart pharmacy . i do need more cialis and finasteride . [doctor] okay . [patient] i would prefer the paper prescription . [doctor] for all of them ? [patient] sure . [doctor] all right , will do . i'm gon na get your prescriptions . [patient] okay , thank you .

CHIEF COMPLAINT Hypogonadism. HISTORY OF PRESENT ILLNESS Mr. Paul Edwards is a 59-year-old male, an established patient, who presents to the clinic today for hypogonadism. He was last seen on 11/24/2020. The patient’s history includes positive for HIV, and today he is concerned with gynecomastia. The patient is doing well, overall, and feels the testosterone is helping. He reports weight stability, feels lively, good, more vigorous, and he is sleeping well. He also thinks the testosterone is having a positive effect on his blood work. He endorses that his triglycerides have always been elevated and adds that they were as high as 265 mg/dL. The patient presented a copy of his bloodwork, showing a significant decrease in his cholesterol after 5 months. Mr. Edwards questioned if the changes in his blood work were due to the testosterone. He also noted that his red blood cell count has not increased. The patient inquired about possible benefits of Indole-3-carbinol, which is a broccoli extract for estrogen control. Currently, the patient is dosing 140 ng/dL of testosterone per week and inquired if his dose could be increased to 175 ng/dL. He recalled that he had recently injected testosterone before his last testosterone blood work was performed; last testosterone levels were greater than 1500 ng/dL. The patient confirms continued daily use of Finasteride and Cialis, prescribed by me, and stated he needs a refill for both. Mr. Edwards mentioned he is taking correct steps to get his life "together." He also uses a med calendar to help with medication compliance. PAST HISTORY Medical HIV SOCIAL HISTORY Utilizes med calendar to support medication compliance. Actively trying to get his life together. CURRENT MEDICATIONS Cialis 5 mg tablet by mouth on days he exercises, 2.5 mg tablet by mouth on days without exercise. Finasteride 5 mg half tablet daily. Testosterone cypionate 140 mg. RESULTS PSA 0.6 ng/mL. Triglycerides 145 mg/dL. Total testosterone 1500 ng/dL, 11/24/2021. ASSESSMENT • Hypogonadism. PLAN I recommend maintaining current management. The patient’s last testosterone levels were greater than 1500 ng/dL, although this level was likely related to his recent injection. He requested an increase to his testosterone cypionate from 140 mg to 175 mg, which I denied due to his already high testosterone levels. I counseled the patient on the risks associated with high testosterone levels and Indole-3-carbinol and it’s lacking evidence to support his estrogen levels. The last time his estradiol levels were checked, they were normal; recommend annual screening. I provided paper prescription refills for Cialis and Finasteride.

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D2N024

[doctor] patient is pamela cook . medical record number is 123546 . she's a 36-year-old female post bilateral reduction mammoplasty on 10-10 20-20 . [doctor] hey , how are you ? [patient] good . how are you ? [doctor] i'm doing well . it's good to see you . how have you been ? [patient] i've been doing good . [doctor] great . how about your breasts , are they doing all right ? [patient] great . [doctor] are you having any chills , fever , nausea , or vomiting ? [patient] no . [doctor] good . all right . let's take a peek real quick . [patient] sure . [doctor] how's life otherwise ? pretty good ? nothing new ? [patient] no , just enjoying summertime . [doctor] okay . how's your family ? [patient] they're good . [doctor] good . all right . i'm going to take a look at your breast now . if you would just open up your gown for me . [doctor] everything looks good . [patient] yeah . [doctor] how's your back pain ? [patient] i'm not really having any more . [doctor] any hard spots , lumps , or bumps that you've noticed ? [patient] i did when i came in last time when i saw your pa , ruth sanchez in march . she said i , she said she found a lump right here under my left breast , but i have n't felt it since then . but i did the massages . [doctor] okay , well . that that's good . uh , it's probably just the scar tissue , but everything looks good and you're healing wonderful , so . [patient] i told her that the scars here was kind of bothering me and i got scar gel . i was using it everyday , but i do n't think i need it now . [doctor] yeah , that scar did widen a little bit . let me take a closer look , hang on . this one widened a little too , ? the incisions are well healed though with no signs of infection or any redness on either breast , so i'm not concerned . [patient] yeah , but this one just bothered me a little bit more . [doctor] i understand . um , you can close your gown now . [doctor] the only thing that is really going to help out that is to uh , to cut it out and re-close it . [patient] [doctor] and you do n't want that , ? [patient] i mean , not right now . [doctor] um , you want to come back and revisit um , maybe six months ? [patient] yeah , i will do that . i still have n't , i still have some more of the gel and i can try using that again . [doctor] okay . keep doing that twice a day . the gel is going to lighten the color a little bit , which is already pretty light . um , but , just in that area , and it's high tension , so it's going to rub a little bit . [patient] yeah , but it kind of bothers me a little bit . [doctor] uh , i do see that . like i said , the only way to really fix that is to cut it out . [patient] uh- . [doctor] um , let's take a look in six months and then we'll go from there . sound like a plan ? [patient] but we have n't hit a full year yet . [doctor] i know . um , i would n't do any revisions anyway for scar tissue until we're at least a year out anyway . [patient] okay . [doctor] so let's wait those six months . you can keep using uh , the mederma scar gel twice a day . massage and scar gel will help for the scars . um , you can put it on other scars too , if you need . [patient] okay . [doctor] um , so that's what i would do . let's just get some pictures today so we can keep up um , with them . and keep an eye on these scars and then we'll go from there . [patient] sounds good . [doctor] all right , well it's good to see you . i'm glad you're doing well . [patient] yeah , same here . [doctor] all right . well , i'm going to tell the front desk six months and we'll revisit those scars . [patient] all right . [doctor] thank you . they're gon na come get your photos now , okay ? [patient] okay .

CHIEF COMPLAINT Follow up bilateral reduction mammoplasty. HISTORY OF PRESENT ILLNESS Pamela Cook is a 36-year-old female who is returning for a postoperative visit. Status post bilateral reduction mammaplasty 10/10/2020. The patient was last seen in clinic by Ruth Sanchez, PA in 03/2021 at which time there was a lump along the left breast, and she was advised to perform massages. Today, Ms. Cook reports she is doing well and that her breasts feel great. She is no longer suffering from back pain. The left breast lower incisional lump from last visit has resolved with massaging and use of scar gel. She reports that the scar on her breast has been bothersome. The patient denies fever, chills, nausea, or vomiting. CURRENT MEDICATIONS Mederma scar gel to incision. PHYSICAL EXAM Breast Bilateral breast incisions well healed with widening of the scar tissue. No signs of infection or erythema. ASSESSMENT • Status post bilateral reduction mammoplasty. Pamela Cook is a 36-year-old female who is status post bilateral reduction mammaplasty on 10/10/2020. There is some widening of the scar tissue bilaterally. PLAN - Obtain bilateral breast photos today to monitor scarring. - Continue Mederma scar gel and incisional scar massage twice daily. INSTRUCTIONS Follow up in 6 months to reevaluate scars.

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D2N025

[doctor] next patient is nicole miller . date of birth is 09/18/1949 . patient was called for a follow-up with me for chronic congestive heart failure with diastolic dysfunction . bmp's been , uh , 3,000 in march , and is about six- was up to 6,000 in april . she was increasingly dyspneic . we changed her furosemide and torsemide 20 milligrams by mouth daily . uh to note , the patient is not currently on potassium supplement . her lisinopril had- has also been increased up to 10 milligrams daily in march . also did when i saw her last april . she reported being interested in having her right knee replaced this summer at east metro . it was recommended that we work to control her cardiovascular status before surgery . [doctor] hey , miss miller , how are you today ? [patient] i'm doing okay , thank you . [doctor] i asked you to come in today because we want to keep- we want you to have this knee surgery this summer but we want to keep a close eye on you to make sure a week before your surgery you do n't suddenly go into congestive heart failure and it gets postponed . [patient] yeah , that would not be good . [doctor] i see you're scheduled on the 24th for surgery . [patient] yeah , that's right . [doctor] okay , good . well it looks like you have lost about 3 , 3 and a half pounds since i saw you last in april . some of that might be water weight , but still , this is positive . [patient] yeah , i noticed that too . i think the oxyglutinine is helping as well . my urgency to use the bathroom is much better . [doctor] well that's great . [patient] yeah , i , i'm pleased about it too . [doctor] you ever get leg or finger cramps or anything like that ? [patient] yeah , i had leg cramps the other day , but i thought it might , was maybe just because i was cold as i had my ceiling fan on and fell asleep . i had cramps when i woke up in both legs right here . um i drank pickle juice and it went right away . [doctor] well do n't , do n't get crazy with the pickle juice because all of the salt in it . [patient] haha , i know , i only drink about 4 ounces or so . [doctor] okay good . [patient] um it went away so i did n't drink anymore . i find it works a lot better than trying to put some cream on my leg . [doctor] sure just , just keep it in moderation . [patient] okay . [doctor] and then are you still on an iron supplement ? and are you using the bathroom okay ? [patient] uh yes , everything is good . [doctor] good . how is your heart burn doing ? any problems with that ? [patient] no , it did get bad for a while so i tried to take some prilosec and then stopped that other one . [doctor] okay . [patient] um i did that for like , gosh , i think it was two weeks back in january and have n't had any problems since . [doctor] great . [patient] um and after i stopped taking that um i went back to the stomach one , so i'm doing good now . [doctor] okay and you're still due for a colonoscopy , correct ? [patient] uh yeah , that's right . [doctor] all right , let's review your blood work real quick . i checked your hemoglobin level because you have had some anemia in the past but that is still doing great . [patient] good , that's a relief to hear . [doctor] your potassium is 3.9 so it's holding steady on the torsemide . your creatinine was .7 not .8 so you're doing well with kidney numbers . your bun may be a tiny bit elevated at 23 which is the number we look for for dehydration sometimes the kidneys , but it's not terrible . um so when i look at your numbers as a whole i think you're tolerating the torsemide okay at the current dose . i also sent out to look at the heart failure number- i sent to look at your heart failure number . there is a test called a bmp that i was monitoring and in march it was up to 3,000 and then went up to 6,000 in april before i made the change . i'm still waiting for those results . [patient] okay . [doctor] all in all i think you're doing good on paper though . [patient] what about , um what's it called , a1c ? does that show up ? [doctor] um i do n't think i ordered it but i could . your last a1c was 5.5 in march . [patient] all righty . [doctor] so your blood sugar is a little bit high , it was 169 today but that kind of depends on what you ate and you were n't fasting for the blood check so i might have to repeat that test for pre-op , but i do n't think we need to do it today . [patient] all righty that sounds good . [doctor] i checked your magnesium level because sometimes you uh urinate out magnesium with the water pills but it was normal at 1.7 and your blood pressure is also looking good . [patient] okay great . that all sounds awesome . [doctor] all right let's take a quick listen . [doctor] use my general physical exam template . [doctor] and take a couple of deep breaths for me . [doctor] your lungs sound pretty good to me so keep doing what you're doing . um uh , like i said , i think you're doing good overall but let's just talk about a few things . [patient] all righty . [doctor] so we often like to keep people with heart problems on magnesium and get their levels up to around the 2-ish range . yours is a little bit less than 2 and we want that 2-ish range because it can help stabilize the heart muscle . so i might recommend putting you on magnesium supplement . it's supposed to be twice a day so that's kind of annoying , but i know you're on other medicines twice a day too , so i think you'll do fine . [patient] yeah , that'll be okay . [doctor] great . now before surgery we'll have to get you off your clopidogrel for a week beforehand . [patient] yes , okay , i have everything written down on my phone , and i have a letter taped to the side of my bed to remind me . [doctor] perfect ! we will give you a reminder as well . we will also need to complete a pre-op check within two weeks of your surgery during the first or second week of june . [patient] okay , i'll put that down . [doctor] you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekgs . um we do n't need to any x-rays of your chest because you had one recently , and we do n't need any more blood work because we did that today . [patient] yeah , i do a lot of ekgs . i'm basically a regular . but i'm happy to do one today , no problem . [doctor] lastly , once we get your knee surgery , um we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ? [patient] yeah , i have both . [doctor] okay so yes , you can get it , your colonoscopy , wherever you'd like . [patient] okay , well my husband's insurance may be running out . might we be able to get the procedure done sooner ? maybe in the next 30 days ? is that okay ? [doctor] um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery . [patient] okay , good . [doctor] so let me see . i've been doing one of two things at every one , and everyone is great so it depends more on timing availability of their or for the colonoscopy . we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical , and they do it at springfield . [patient] okay , that sounds good . [doctor] i think either direction they're good technicians of the colon . [patient] okay , yeah whatever you can get me in , that works great . [doctor] so i'll call around . now if you get that done and they tell you 10 years then you'll be good to go . [patient] great , thank you . [doctor] you're welcome . have a great day . let us know if you need anything else , okay ? [patient] sounds good . [doctor] all right , assessment and plan . [doctor] chronic chf . mixed presentation . had a exacerbation of cf , chf earlier in the spring . we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about 3 , 3 and a half pounds down in weight . breathing is non-labored . going to repeat ekg today but otherwise continue with her current regimen . labs checked and creatinine is appropriate . [doctor] uh number 2 , pre-op examination . she is , she's having a right knee replacement end of june . also , she would like to have a colonoscopy performed which we'll try to have done at uh bartley regional , rightley regional hospital in the next month , uh , prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer . [doctor] uh the next one is diabetes . a1c is 5.1 on the last check so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .

CHIEF COMPLAINT Follow-up. HISTORY OF PRESENT ILLNESS Nicole Miller is a 71-year-old female who presents for follow-up. The patient was called in for a follow up with me for chronic congestive heart failure with diastolic dysfunction. Her BNP had been 3000 in 03/2021, up to 6000 in 04/2021. She was increasingly dyspneic. We had changed her furosemide to torsemide at 20 mg by mouth daily. The patient is not on a potassium supplement currently. Her lisinopril had also been increased up to 10 mg daily in 03/2021. I last saw her in 04/2021, and she had reported being interested in having her right knee replaced this summer at East Metropolitan Hospital, so it was recommended that we work to control her cardiovascular status prior to surgery. She is currently scheduled to have surgery on 06/24/2021. She plans to discontinue clopidogrel a week before her surgery. The patient states that she has lost approximately 3 to 3.5 pounds since her last visit in 04/2021. Some of which may be water weight decreasing. She did report experiencing bilateral leg cramps which she treated with consumption of pickle juice, which did resolve the cramps. She thought the cramps were related to her being cold. She is still taking iron supplementation. She denies any concerns with defecation. Regarding her prior symptoms of heartburn, she denies any recent gastrointestinal issues. She notes that her heartburn was severe at one point but resolved after trying Prilosec for 2 weeks in 01/2021. She denies any issues with heartburn since that time and has stopped taking Prilosec altogether. She has since transitioned back to her original "stomach medication". The patient is due for a colonoscopy. She is currently double covered with Medicare and private insurance. PAST HISTORY Medical Chronic Congestive Heart Failure. Iron deficiency Anemia. Medications Prilosec. FAMILY HISTORY No family history of colon cancer. CURRENT MEDICATIONS Torsemide 20 mg by mouth daily. Lisinopril 10 mg daily. RESULTS Magnesium 1.7, hemoglobin WNL, potassium 3.9, creatinine 0.7, BUN 23. 03/2020 Hgb A1c 5.5. ASSESSMENT • Chronic congestive heart failure with mixed presentation. • Preop examination. • Diabetes mellitus. • Colonoscopy PLAN Chronic congestive heart failure with mixed presentation. She had an exacerbation of CHF earlier in the spring. We switched her from furosemide to torsemide and symptomatically, she is doing a lot better. She is about 1.5 kg down in weight. Her breathing is nonlabored. We are going to repeat an EKG today. Otherwise, continue her current regimen. Labs were checked and creatinine is appropriate. Her magnesium is below the preferred 2 at 1.7, with some occurrence of bilateral leg cramping, therefore we will start her on magnesium supplement. Preop examination. She is going to be having a right knee replacement at the end of 06/2021. We will schedule a preop check the first week or two of June prior to the surgery. She will discontinue clopidogrel for one week prior to knee replacement surgery; we will provide a reminder to patient of this as well. Diabetes mellitus. A1c is 5.5 on last check, so there is no need for a further A1c today. She may need another one prior to her surgery next month. Colonoscopy. The patient is overdue for a colonoscopy, which we will try to have done at County Hospital in the next month, prior to a change in her insurance. This is just a screening colonoscopy that she is overdue for. No family history of colon cancer. The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS Complete EKG today. Schedule a preop checkup 1st or 2nd week of June. Start magnesium supplement. Call the clinic with any questions or new symptoms.

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D2N026

[doctor] dictating on donald clark . date of birth , 03/04/1937 . chief complaint is left arm pain . hello , how are you ? [patient] good morning . [doctor] it's nice to meet you . i'm dr. miller . [patient] it's nice to meet you as well . [doctor] so , i hear you are having pain this arm . is that correct ? [patient] that's correct . [doctor] okay . and it seems like it's worse at night ? [patient] well , right now the hand is . [doctor] mm-hmm . [patient] and the thing started about two weeks ago . i woke up about two o'clock in the morning and it was just hurting something awful . [doctor] uh- . [patient] and then i laid some ice on it and it finally did ease up . [doctor] okay , that's good . [patient] so i got up , i sat on the side of the bed and held my arm down , thinking it would , like , help the circulation , but it did n't . [doctor] okay , i see . [patient] and so , after a while , when it eased off , maybe about four , five am , i laid back down and it did n't start up again . [doctor] mm-hmm , okay . [patient] um . i went back to sleep but for several nights this happened , like , over and over . so , i finally went to see the doctor , and i do n't really recall her name . [doctor] okay . yeah , i think i know who you're talking about , though . [patient] um , she's the one who sent me to you , so , i , i would , i would think so . but when i went to her after the third time it happened and she checked me out , she said it was most likely coming from a pinched nerve . [doctor] probably . uh , do you notice that moving your neck or turning your head seems to bother your arm ? [patient] uh , no . [doctor] okay . is moving your shoulder uncomfortable at all ? [patient] no . [doctor] and do you notice it at other times besides during the night ? [patient] um , some days . if it bothers me at night , then the day following , it usually will bother me some . [doctor] okay . and do you just notice it in the hand , or does it seem to be going down the whole arm ? [patient] well , it starts there and goes all the way down the arm . [doctor] okay . have you noticed any weakness in your hand at all ? [patient] uh , yes . [doctor] okay . like , in terms of gripping things ? [patient] yeah . [doctor] okay . [patient] uh , this finger , i hurt it some time ago as well . [doctor] really ? [patient] yeah . it does n't work properly . or , it works very rarely . [doctor] gotcha . and did i hear that she gave you some prednisone and some oral steroids , or ? [patient] uh , well , she gave me some numbing medicine . it helped a little bit . the other two were a neck pill and gabapentin . uh , you should have my full list in your notes , though . since then it has n't really bothered me at night . also , just so you know , i am a va and i'm one percent disabled from this leg , um , issues from my knees down to my feet . [doctor] okay . is it neuropathy ? [patient] uh , yep . [doctor] gotcha . that is good to know . all right , well , let's go ahead and take a look . [patient] okay . [doctor] all right . so , to start , i'm gon na have you do something for me . uh , just go ahead and tilt your chin as far as you can down to your chest . okay , good . and now , go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay . and now , come back to normal , just look and turn your head as far as you can that way . great . and now , as far as you can towards that wall . uh , does that seem to bother you at all ? [patient] no . well , actually , i do feel a little strain . [doctor] okay . so , you feel it in the neck a little bit ? [patient] yeah , just a little strain . [doctor] okay . uh , now squeeze my fingers as hard as you can with both hands . great . now , hold your arms like this . [patient] okay . [doctor] and i'm going to try to strain your arms and try to keep them as stiff as you can . do n't let me strain it . okay , good . good . now , when i , i'm just touching your hands like this . does it seem to feel about the same in both hands ? [patient] uh , yes . [doctor] okay . all right . so , i do agree with betty . uh , more than likely , this seems like it would be coming from your neck . that's the most common reason that causes what , what you're experiencing . and i looked at an x-ray of your neck , and you do seem to have a lot of arthritis there , and there does seem to be potential for a disc to be pushing on a nerve . and now , what i do n't have is an mri , which would show me , uh , kind of exactly where the nerve roots are getting pinched off . [patient] i see . [doctor] so , gabapentin can help a little bit with the nerve pain , and what i would like to do is potentially set you up for an epidural . and what that is is it , it's a focused anti-inflammatory medicine , excuse me , that works behind the nerve roops that , nerve roots that we are thinking might be getting squished off . it can often help alleviate your symptoms , and i do need to get an mri of your neck . um , i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so , what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see right where i need to put the medicine for your epidural . uh , what do you think of that ? [patient] i think that sounds good to me . [doctor] okay , good . and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list . [patient] uh , no , i do n't . [doctor] okay , good . and what i would have you do is continue with the gabapentin . um , are you taking 300 or 100 ? [patient] um , not sure . my lady friend helps me handle this stuff . [doctor] okay . [patient] i am taking eliquis , though . [doctor] okay . um , so whatever you are doing you can just keep doing it , and i'm going to set you up for the epidural and imaging study , um , just so i know right where to put the medicine . and i will follow up with you after s- um , that's in . we can do the shot , just to make sure your arm is feeling better . sound good ? [patient] sounds good . for the last couple of nights , though , my neck has not been bothering me . [doctor] okay . s- um , so , presumably what's happening , then , is when you're sleeping your neck is kind of gets off-tilt , uh , kilter , and it compresses the nerve roots there . now , if you think you're doing fine , we could hold off , but at the very la- least , i'd like to update that mri of yours and see what's going on , because probably this is something that will likely flare up again . [patient] yeah , it , it has been for the last week , so , i understand . [doctor] okay . all right . well , do you want to do that work-up and do the epidural , or do you think you're doing fine and you want to wait ? [patient] well , my hand is still bothering me . [doctor] okay . so , you're saying your neck is not bothering you but the hand is . okay . so then , let's just stick with the plan . mri of the neck , so we can see where the nerve roots may be compressed , that's giving your hand the issue . and then , we're going to set you up with the epidural . [patient] okay . sounds good . [doctor] all right . so , keep going with the gabapentin . i will order the imaging of your neck , and the shot will hopefully help some with those symptoms in your hand , and then we'll follow up afterwards . [patient] all right . is the mri today ? [doctor] um , you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute , and then roy will come in and get things scheduled as soon as we can . [patient] all right . [doctor] all right . well , it was nice meeting you , my friend . [patient] you as well . thank you . [doctor] physical exam , elderly white gentleman presents in a wheelchair . no apparent distress . per the template , down through neuro- neurologic . one plus bilateral biceps . triceps brachioradialis . reflexes bilateral all negative . follow up and take out the lower extremities . gait not assessed today . strength and sensation is per the template . uh , upper and lower extremities . musculoskeletal , he is non-tender over his cervical spine . he does have mildly restricted cervical exte- extension . right and left lateral rotation which is symmetric , which gives him mild lateral neck pain but no radi- radicular pain . spurling's maneuver is benign . [doctor] paragraph , diagnostics . cervical x-ray 6421 . cervical x-ray reveals significant disc degeneration at c56 , and to a lower extent c45 and c34 . significant lower lumbar facet arthropathy c67 and c7-t1 is difficult to visualize in the current x-rays . [doctor] paragraph , impression . number one , left upper extremity neuropathy suspicious for cervical radicularopathy . possible contribution of peripheral neuropathy . number two , neck pain in the setting of arthritis disc degeneration . [doctor] paragraph , plan . i suspect that this is a flare of cervical radicularopathy . i'm going to set him up for a cervical mri , and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .

CHIEF COMPLAINT Left arm pain. HISTORY OF PRESENT ILLNESS He reports that his left arm pain began approximately 2 weeks ago. He woke around 2:00 am with intense pain in his left arm and hand. He applied ice and after 2-3 hours, the pain improved and he was able to go back to sleep, the pain did not return until that evening. After several nights of experiencing the left arm and hand pain, he was seen by Betty Ross, PA-C. She suspected a pinched nerve and completed x-rays of the cervical spine, prescribed gabapentin and prednisone, and referred the patient to us. The patient has benefited from the gabapentin and prednisone, reporting improvement of pain at night. The pain initially was encountered at night, but the patient notes that the symptoms carry into the next day. He denies pain when moving his neck, turning his head, and moving his shoulder. Mr. Clark does report a history of a left finger injury, stating “it rarely works”, and neuropathy in one leg from his knee to his foot which he receives 1% disability for. The patient is a veteran. PAST HISTORY Medical Peripheral neuropathy. SOCIAL HISTORY The patient is a veteran and receives 1% disability. CURRENT MEDICATIONS Gabapentin tablet. Prednisone tablet. PHYSICAL EXAM Constitutional Elderly Caucasian male in no apparent distress. Presents in wheelchair. Neurologic Upper extremities: 1+ bilateral biceps, triceps, brachioradialis, reflexes bilaterally, negative. Negative Hoffman's Gait: Not assessed today. Strength Upper extremities: Normal throughout the biceps, triceps, deltoid, grip strength, and finger abduction, bilaterally. Sensation: Intact to light touch throughout the upper and lower extremities. Musculoskeletal Cervical: Nontender over cervical spine. Mildly restricted cervical extension and right and left lateral rotation, which is symmetric, which gives him mild lateral neck pain, but no radicular pain. Spurling's maneuver is benign. RESULTS X-ray Cervical Spine, 06/04/2021. Impression: Significant disc degeneration at C5-6 and to a lesser extent C4-5 and C3-4. Significant lower facet arthropathy. C6-7 and C7-T1 are difficult to visualize in the current x-rays. ASSESSMENT • Left upper extremity neuropathy, suspicious for cervical radiculopathy, possible contribution of peripheral neuropathy • Neck pain in the setting of arthritis and disc generation PLAN I suspect that this is a flare of cervical radiculopathy. I am going to set him up for a cervical MRI. We will tentatively plan for a left C7-T1 epidural afterwards, although the exact level will be pending the MRI results. He will continue his home exercise program as well as twice daily gabapentin. We will follow up with him afterwards to determine his level of relief. He denies any blood thinners. This plan was discussed in detail with the patient who is in agreement. INSTRUCTIONS Continue home exercise program and twice daily gabapentin. Schedule MRI and epidural injection. Follow-up after epidural.

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D2N027

[doctor] eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions . [doctor] of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the patient's alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . [doctor] good morning , mr. walker . how are you doing ? i mean , it's been a crazy year . [patient] i'm doing fine , for the most part , but there are a few things i want to cover today . [doctor] sure . go right ahead . [patient] uh , well , i'm having more fatigue , but i do n't know if it's age or if it's just , you know , drained at the end of the day . but i still ride my bike . i ca n't go as fast as i used to . i'm still riding , and , you know , after a long bike ride , i'll sit down and then boom . i'm out , you know ? [doctor] yeah . what's a long bike ride to you ? [patient] uh , 20 to 30 miles . [doctor] 20 to 30 miles on a road bike ? [patient] yeah , road bike . i think it's a time thing . if i had more time , i would try to do my 40 miles , but i have n't done that . obviously , we're too early in the season so my typical ride is , like , 20 , 30 . in years back , i could do 40 on a good day . i can still do 20 but , you know , i'm tired and have to take a break when i get home . [doctor] yeah , i understand . [patient] and tyler's my buddy . he's always nice and waits for me , but i used to be able to beat him . but now , he waits for me all the time . he's older than me and it- it kills me . [doctor] yeah , i can imagine that would upset me too . [patient] well , the last time , you know , you found a heart thing , then . just making sure that the valve is holding out , you know ? [doctor] right . so , when was your last stress test ? [patient] it was september 9th , 2019 , because i'm eight years out from surgery , and back then , they said , you know , it's going to last eight years . and i'm at that year , so i just want to make sure . i asked dr. lewis for an echocardiogram to see how i'm doing . [doctor] yeah . [patient] but it's not ... like , nothing has changed drastically since i saw you . [doctor] okay , good . do you still go down to hopkins at all ? [patient] no , not at all . i just get follow-ups intermittently , here . going there is just ... it's too much stress . [doctor] okay . [patient] one more thing , i want to make sure i do n't forget . my wife and friends tell me that when i walk , i purse my lips when i'm breathing . other doctors have said , " did you notice your pursed lips breathing ? " i do n't know if that's a bad habit or what . [doctor] okay . is there any wheezing associated with that ? [patient] no , no wheezing . [doctor] and you're able to bike 30 miles and mostly keep up with your friend , tyler , correct ? [patient] yeah . the only other thing i want to mention is it's not like i do routine testicular exams , but i know i have this little nodule on my right testicle . [doctor] on the testicle or the epididymis ? [patient] epididymis . uh , i really do n't know . i'm not super concerned . i read a little online . just wanted to ask you . [doctor] and did you have a vasectomy ? [patient] no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those were the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know ? i just know you would ask those questions . [doctor] what time are you going to sleep , and about how many hours do you sleep a night ? [patient] um , it varies . usually , i get six to seven hours of sleep . i get out of bed some days to be at work by 7:00 , lecture , and i try to work out in the morning . i- i do n't ... i'm not ... i'm not always successful , and now what i do is i- i do make reservations twice a week for a 5:45 swim in the morning . [doctor] okay , so you're getting six to seven hours of sleep , and has your wife ever mentioned if you snore or stop breathing at any time ? [patient] i believe i snore a little bit , but she's never said anything about me not breathing . [doctor] okay . so , you're currently taking vitamin d3 , around 5000 units on sundays , and two thous ... or 50,000 units on sundays , excuse me , and 2000s on the other six days , and then clindamycin prior to dental procedures , correct ? [patient] yeah , that's right . [doctor] have you had a covid-19 shot yet ? [patient] i've received both . my first dose on january 15th , '21 and my second on february 5th , '21 . [doctor] good . if you'd hop up here on the table , we're just going to do a physical exam . [doctor] well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you . [patient] all right . [doctor] also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today . [patient] you're going to have them done today ? [doctor] yes , sir , and we will send the results through your patient portal unless something is way off then we'll give you a call . [patient] sounds good . [doctor] now as far as your breathing , i observed the pursed lip breathing and your exhalation is low . i think you should do a pulmonary function test to further evaluate , and i'll order that as well . [doctor] now the nodule in your right testicle should be evaluated by urology , and we will place that referral today , also . [patient] sounds like i'm going to be busy getting this all checked out . [doctor] yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good . [doctor] now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies . [doctor] do you have any other questions for me ? [patient] no , doc . i think you covered it all . [doctor] great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month . [patient] thanks , doc . have a great day . [doctor] all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default . [doctor] assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test . [doctor] elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt . [doctor] lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation . [doctor] the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound . [doctor] preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 . [doctor] patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .

CHIEF COMPLAINT Routine follow up of chronic medical conditions. HISTORY OF PRESENT ILLNESS Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions. Today, the patient reports feeling more fatigued as of late. He notes that he usually rides his bike for about 20 to 30 miles and by the end of his ride he is tired enough that he will immediately fall asleep. The patient adds that he can fall asleep easily and gets about 6 or 7 hours of sleep per night. He believes he snores a bit but denies any signs of apnea. Of note, the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 01/22/2013. As he is now 8 years post-op, he has requested an echocardiogram from Dr. Lewis to review how he is doing currently. His last stress test was performed on 09/09/2019. Mr. Walker reports that his wife and friends have told him that he has pursed lips when he walks. This has also been noticed by his other providers. He denies any wheezing. Furthermore, the patient has noticed a 2 to 3 mm nodule in his right testicle, possibly with the epididymis but he is unsure. He has not had a vasectomy. His current medication list only consists of clindamycin prior to dental procedures and vitamin D3 (50,000 IU on Sundays and 2000 IU the other 6 days). From a preventative standpoint, the patient is due for the shingles vaccine and an MMR titer. He is fully vaccinated for COVID-19 with his first dose on 01/15/2021 and his second dose on 02/05/2021. PHYSICAL EXAM Respiratory Pursed lip breathing noted. The exhalation phase is low. Lungs are clear to auscultation, no wheezing. Genitourinary No hernia noted. Left testicle normal. RESULTS Regarding his blood work from 04/10/2021, the patient's alkaline phosphatase was elevated at 156. His lipid panel showed elevated total cholesterol of 247, HDL 66, LDL 166, and triglycerides 74. The patient's TSH was normal at 2.68. His CBC was unremarkable. His most recent vitamin D level was at the high end of normal at 94. ASSESSMENT • History of aortic aneurysm repair. • Elevated alkaline phosphate level. • Lung field abnormal finding on examination. • Right testicular nodule. • Preventative health. PLAN Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions. History of aortic aneurysm repair. - Overall, he is doing well and currently asymptomatic. - Currently he is not seen by cardiology routinely and I have suggested he follow up with Dr. Tyler Sanchez. - Ordered echocardiogram and stress test. Elevated alkaline phosphate level. - Most recent CMP showed elevation at 156 IU/L. - This could be related to his liver but most likely related to his bone health. - Ordered an alkaline phosphatase and gamma GT. Lung field abnormal finding on examination. - The patient has been noted to purse his lips while breathing. - He had found himself feeling more fatigued at the end of the day. - He does cycle 20 to 30 miles at a time. - His exhalation phase was low on exam. - Ordered pulmonary function testing for further evaluation. Right testicular nodule. - 2 to 3 mm nodule noted on exam. There is no palpable hernia. - Referral placed to urology for possible ultrasound. Preventative health. - Most recent blood work reviewed with no significant abnormalities. - He is fully vaccinated against COVID-19. - Recommend shingles vaccine next month. - MMR titer performed today. INSTRUCTIONS - Return in 1 year for routine wellness visit, sooner if needed. - Call with any questions or concerns.

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D2N028

[doctor] patrick allen . date of birth : 7/7/1977 . new patient visit . past medical history includes gerd , anxiety , depression . here for chronic abdominal pain . he had an abdominal ct on 1/23/2020 . impression is a normal ct of the ab- abdomen . [doctor] hello , are you mr. allen ? [patient] yes , i am . [doctor] hi . my name is dr. edwards . nice to meet you . [patient] nice to meet you . [doctor] welcome to the gi specialty clinic . [patient] thank you . [doctor] did you have any problems finding us ? [patient] no , i've been here with my sister once before . [doctor] good . so how can i help you today ? uh , the referral i have is for abdominal pain and diarrhea . [patient] right . so i've had ... i've been having this pain right here in my stomach , like right around here . [doctor] so in the area of your mid abdomen , just below the belly button ? [patient] correct . i've had the pain on and off for about two years . i finally went to the er and a ... a few months ago and they did a ct scan . [doctor] i saw that . [patient] yeah . they said they did n't really see anything on the scan . [doctor] yes , i agree . it looked normal . [patient] the problem is i'm either constipated or have explosive diarrhea . [doctor] is the pain there all the time ? [patient] it's a nagging feeling and it just depends . sometimes it bothers me , sometimes it does n't . [doctor] has this been the case over the past two years as well ? [patient] more recently in the past couple months , at least with the constipation and diarrhea . [doctor] and before that , how are your bowel movements ? [patient] they were normal . [doctor] uh , okay . so any blood in your stool ? [patient] nope . [doctor] do you feel like you have more constipation or diarrhea ? [patient] probably more constipation . [doctor] okay , so when you're constipated , do you not have a bowel movement or is the stool hard ? [patient] i usually do n't go , but when i do , it's hard . [doctor] and how often do you have a bowel movement when you are constipated ? [patient] about three to four times a week . it's like when i need to go to the bathroom , if i can massage it , it feels like it's moving some and i can eventually go . [doctor] okay . and when you have a bowel movement , does the pain change ? [patient] yeah , it gets a little better . [doctor] and are you eating and drinking okay ? any nausea or vomiting , heartburn or indigestion ? [patient] none of that . [doctor] okay . so tell me about the diarrhea , how often do you get it ? [patient] it kinda just depends on what i eat . i think i have a very sensitive stomach . if i eat pasta with a creamy sauce , i'm probably gon na have diarrhea . [doctor] okay . and it does n't happen for multiple days in a row or is it just one time ? [patient] it's usually just one time and then it's over . [doctor] and how's your weight been ? any fluctuation ? [patient] nice and pretty stable , although i could stand to lose about 25 pounds . [doctor] okay . and is there any family history of gi issues that you know of ? [patient] not that i can think of . well , actually my sister does have problems with her stomach too . she has irritable bowel syndrome and that is kind of what i always thought i had even thought i've never been diagnosed with it . [doctor] okay . and is there any family history of gi cancer or liver disease ? [patient] nope . [doctor] have you ever had any surgeries on your abdomen ? [patient] i've never had any surgery . [doctor] okay , so your gallbladder , appendix , all those are still intact ? [patient] yup . [doctor] and have you ever had a colonoscopy ? [patient] no . i thought that happen when you turn 50 . [doctor] well , that's for colon cancer screening , but there are other reasons to have a colonoscopy , like unexplained abdominal pain and changes in bowel habits . [patient] okay . [doctor] well , come have a seat here and lay back so i can examine you . [patient] okay . [doctor] i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants . [patient] what does that mean ? is everything okay ? [doctor] it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working . [patient] okay , good . [doctor] so now , i'm going to push on your upper and lower abdomen . let me know if you have any pain . [patient] it hurts a little when you push right there on the left side , near my belly button . [doctor] okay . i do feel stool in your lower colon , which would coincide with constipation , but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ? [patient] yes , i have a physical about four months ago and they ... i had blood drawn then . [doctor] okay . and did your primary care physician say anything about the lab results ? [patient] he said i had some very slightly elevated liver enzymes , but we would recheck them in about six months . [doctor] and you remember what enzymes were elevated , alt , ast , alp ? [patient] he said the alt and the ast were elevated . [doctor] and do you take any medications , either prescription or over-the-counter ? [patient] i take crestor and olmesartan daily and then tylenol for occasion- occasional pain . [doctor] and how frequently do you take the tylenol ? [patient] hardly ever . maybe once a month . [doctor] and do you consume alcohol ? [patient] uh , yes , but only a couple of beers after working in the yard on saturdays . [doctor] okay . and no previous history of heavy alcohol or drug use ? [patient] nope . [doctor] and have you had any recent issues with excessive bruising or bleeding ? [patient] nope . [doctor] and how about any issues with your ankles or feet swelling ? [patient] no . [doctor] okay . i'm gon na take a look at your eyes and skin . i do n't see any jaundice . [patient] what would cause that ? [doctor] issues with your liver . let me take a quick listen to your heart and lungs . [patient] okay . [doctor] lungs are clear , bilateral heart sounds are normal , no murmurs , gallops , or rubs noted . [patient] that's good . [doctor] yes . the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly . [patient] what's that ? [doctor] increase stool burden means that there's a lot of stool sitting in your colon . [patient] and that's the constipation , right ? but what about the other thing ? [doctor] the hepatomegaly means the liver is enlarged . [patient] but you said mine was slightly enlarged ? [doctor] correct . [patient] so what does that mean ? [doctor] well , let's talk about what we found and then some possible next steps if you're in agreement . [patient] okay . [doctor] so as i said , the hepatomegaly means your liver is enlarged . [patient] could that be why my stomach is hurting and i'm having issues with the constipation and diarrhea ? [doctor] no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that . [patient] so what about my liver ? why is it enlarged ? [doctor] well , there are many reasons why people can have an elevated liver enzymes and also enlarged liver . some possible causes are certain medications that can be toxic to liver , alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease . [patient] so what do i need to do ? [doctor] well , i think since it's been about four months since your blood work was done , we should check your liver enzymes in addition to a few other labs . [patient] okay . and then what ? [doctor] we will get those drawn today and then depending upon the results you may need an ultrasound of your liver . i think we need to talk about your medications too . [patient] which medications ? [doctor] crestor , how long have you been taking that ? [patient] about 18 months . [doctor] okay . well , crestor is one of the medications that can cause liver toxicity so it may be a good idea to discuss other alternatives . [patient] should i talk to my primary care or can you change it ? [doctor] i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol . [patient] okay . i'll call him this afternoon . [doctor] great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that . [patient] okay . when do you think i'll be able to get the ultrasound done ? [doctor] hopefully , within the next two weeks . you will receive a call from the radiology scheduling this afternoon to get it set up . [patient] okay . and then what happens ? [doctor] when i get the results from the test , i will contact you . and depending upon what we find , we'll come up with our next steps . [patient] and when should i see you again ? [doctor] uh , let's schedule an appointment when you check out to return in four weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver . [patient] okay . is there anything else i can do to help with these issues ? [doctor] definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day in addition to taking the fiber supplement to help with your constipation . and be mindful of eating foods that you were sensitive to so you can avoid the bouts of diarrhea . [patient] okay . and i'll talk to my primary care about my crestor . [doctor] excellent . and do you have any other questions for me ? [patient] i do n't think so . [doctor] great . so remember when you check out the front desk , schedule follow-up appointment with me for four weeks and then go to the lab to get your blood work drawn . [patient] okay . sounds good . [doctor] and expect a call from radiology scheduling about setting up your ultrasound . [patient] all right . thanks , dr. edwards . [doctor] thank you , mr. allen .

CHIEF COMPLAINT Abdominal pain and diarrhea. HISTORY OF PRESENT ILLNESS Patrick Allen is a 42-year-old male who presents for a new patient visit for chronic abdominal pain, constipation, and diarrhea. Mr. Allen reports experiencing intermittent mid-abdominal pain for approximately 2 years. The pain is localized just inferior to the umbilicus and he describes it as a “nagging feeling” when it is present. The pain sometimes improves following a bowel movement. Unfortunately, Mr. Allen reports that the pain has been present more often in the past 2 months. In 01/2020, the patient presented to the emergency room due to the pain and underwent a CT scan. In addition to the abdominal pain, Mr. Allen complains of constipation and episodic severe diarrhea for the past 2 months; however, he estimates that the constipation is more frequent than the diarrhea. When he is constipated, he has a bowel movement 3-4 times a week and the stools are hard. Regarding his diarrhea, he has noticed that it seems to be associated with certain foods. In particular, he notes that pasta with a creamy sauce is likely to prompt an episode of diarrhea. When this occurs, he usually has just 1 bowel movement of diarrhea and then it resolves. The patient states that, prior to 2 months ago, his bowel movements were normal. Mr. Allen notes that massaging his abdomen has sometimes been helpful in producing a bowel movement. The patient’s last physical was 4 months ago, and he confirms that he did have bloodwork that day. Mr. Allen reports that his primary care provider notified him that his AST and ALT were mildly elevated and advised that they would need to recheck his liver enzymes in 6 months. The patient’s medication list includes Crestor and olmesartan daily and he estimates that he has been taking the Crestor for approximately 18 months. He also takes Tylenol as needed for pain, approximately once a month. The patient states that he drinks 2 beers once a week and denies a history of heavy alcohol or drug use. He also denies excessive bruising or bleeding and any lower extremity edema. The patient denies blood in his stools, nausea, vomiting, heartburn, and indigestion. He confirms that he is eating and drinking normally, and his weight has been stable. He does acknowledge that he would like to lose 25 pounds, however. He has no family history of gastrointestinal cancer or liver disease; however, his sister has irritable bowel syndrome (IBS). The patient has not had any prior abdominal surgeries and he has never had a colonoscopy. PHYSICAL EXAM Respiratory Lungs clear to auscultation bilaterally. Cardiovascular No murmurs, gallops, or rubs. Abdomen Normoactive bowel sounds in all 4 quadrants. There is mild left periumbilical tenderness to palpation, mild hepatomegaly, and increased stool burden in colon. RESULTS CT of Abdomen, 01/23/2020. Impression: Normal CT of abdomen. ASSESSMENT • Constipation • Mild hepatomegaly PLAN Patrick Allen is a 42-year-old male who presents for a new patient visit for chronic abdominal pain, constipation, and diarrhea. The most likely etiology of his abdominal pain is constipation given his history, exam with increased stool burden, and normal abdominal CT. Mild hepatomegaly was also noted on exam today and the patient reportedly had elevated liver enzymes on labs with his primary care provider 4 months ago. The patient is currently on Crestor which may be contributing to his elevated liver enzymes. We discussed findings, diagnosis, and next steps at length. Constipation • Start daily fiber supplement and increase water consumption to at least 48 ounces daily to help with bowel regularity. • Avoid trigger foods that may cause episodes of diarrhea. Mild Hepatomegaly • Repeat liver enzyme labs today. • Schedule a liver ultrasound pending lab results. • Encouraged to cease alcohol consumption. • Patient to contact his PCP to discuss alternative medications. INSTRUCTIONS Return to clinic in 4 weeks.

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D2N029

[doctor] next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma . [doctor] mrs. jackson , it's good to meet you . [patient] likewise , wish it were under better circumstances . [doctor] yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ? [patient] yes , that's what the biopsy said . [doctor] okay and when did you first notice the spot ? [patient] my mom noticed it when i was visiting her last month . [doctor] i see . and so you went to the dermatologist on april 10th to get it checked out , right ? [patient] yes , i wanted to be extra cautious because skin cancer does run in my family . [doctor] well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ? [patient] my mom and her sister , i think they both had melanoma . [doctor] okay . do you have any other types of cancer in the family , like breast or ovarian ? [patient] my grandfather had pancreatic cancer . [doctor] okay , and was that your mom or dad's father ? [patient] mother's . [doctor] okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ? [patient] no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before . [doctor] good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ? [patient] yes , that's correct . [doctor] okay , and for social history can you tell me what you do for work ? [patient] i own an auto repair shop . [doctor] okay and have you ever been a smoker ? [patient] yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying . [doctor] i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ? [patient] i had gall bladder and appendix . [doctor] okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ? [patient] no , i've been feelin' great . [doctor] good . well let me take a look at your back here where they did the biopsy if you do n't mind . [patient] sure . [doctor] okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ? [patient] okay , that's fine . [doctor] all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . [doctor] okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further . [patient] okay , i should n't worry too much then ? [doctor] no , i have a low suspicion that it will show anything . [patient] okay , good . [doctor] so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision . [patient] okay , that is fine with me , i ca n't see back there anyways . [doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else . [patient] yeah , she did say she wants to see me back . [doctor] good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight . [patient] yeah , she definitely went over that , um , several times with me . [doctor] good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ? [patient] um , no i ca n't think of any at this time . [doctor] okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you . [patient] thank you , nice to meet you as well . [doctor] please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . [doctor] for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . [doctor] primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . [doctor] after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

CHIEF COMPLAINT Melanoma. HISTORY OF PRESENT ILLNESS Sophia Jackson is a very pleasant 57-year-old female who presents for a surgical consult for melanoma of the right inferior back. She was referred by her dermatologist who biopsied the 0.7 mm lesion on 04/10 and diagnosed the melanoma. The lesion was initially noticed by the patient’s mother when she was visiting her last month. Mrs. Jackson denies a personal history of atypical nevi and reports that she has annual mole checks by her primary care provider at her physicals. She has never seen a dermatologist prior to last month. There is a family history of melanoma in her mother and maternal aunt. The patient reports that she has been in her usual state of health with no unintentional weight changes, headaches, fatigue, nausea, vomiting, or vision changes. PAST HISTORY Medical None reported. Surgical Cholecystectomy. Appendectomy. SOCIAL HISTORY Patient owns an auto repair shop. Current smoker since teens. Actively trying to quit. FAMILY HISTORY Mother: melanoma. Maternal aunt: melanoma. Maternal grandfather: pancreatic cancer. No family history of breast or ovarian cancers. MEDICATIONS None. ALLERGIES Augmentin. PHYSICAL EXAM Hematologic/lymphatics: No axillary, cervical, or supraclavicular lymphadenopathy. There is a soft lymph node in the right groin. Nontender. Skin: On the right inferior back there is a 1 cm shave biopsy site including all of the dermis with no residual pigmentation. There’s no intrinsic or satellite lesions. No other suspicious moles. RESULTS Pathology Report. Pathology: Shave biopsy of right inferior back malignant melanoma, invasive, superficial spreading. Histology: Superficial spreading. Clark level: 4. Breslow thickness: 0.7 mm. Radial growth phase: present. Vertical growth phase: not identified. Mitotic figures: less than 1 mm2. Ulceration: not identified. Regression: not identified. Lymphatic invasion: not identified. Perineural invasion: not identified. Microscopic satellitosis: not identified. Infiltrating lymphocytes: breast. Melanocytic nevus: not identified. Predominant cytology: epithelioid. Peripheral margin: positive. Deep margin: Negative. Stage: 1. I reviewed the dermatologist’s photo of the lesion which showed an asymmetric black and brown nevus with central amelanotic component and irregular border. ASSESSMENT AND PLAN The patient presents today with newly diagnosed melanoma. The biopsy revealed an intermediate thickness melanoma. On examination today, there is a right inguinal lymph node with slightly atypical consistency. I recommended an ultrasound to rule out metastatic disease. If the ultrasound is normal, the patient is a candidate for a wide local excision with a 1-2 cm margin. Primary closure should be possible, but skin graft closure may be needed. The relationship between tumor histology and prognosis and treatment was carefully reviewed. The need for follow up according to the National Comprehensive Cancer Network (NCCN) guidelines was reviewed. We also reviewed the principles of sun avoidance, skin self-examination, and the ABCDE’s of mole surveillance. After discussing the procedure, risks, expected outcomes and possible complications, questions were answered, and the patient expressed understanding and did choose to proceed.

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D2N030

[doctor] donna torres , date of birth , 08/01/1980 . [doctor] hi donna ! how are you ? [patient] i'm good . how about you ? [doctor] i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ? [patient] no , that's new . [doctor] okay . how is it working for you ? [patient] my anxiety is going good now , thankfully . i'm serious , it was brutal in november and december . finally , i was like , " i can not do this . " i have no idea why it happened . dr. ward did put me on singulair , and she did say we need to be careful because singulair can cause anxiety . so i'm not sure if that was the issue or what . [doctor] mm . okay . [patient] and it would , um , start usually during the day , at work . [doctor] i see . [patient] i mean , i'm fine now . [doctor] well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too . [patient] i did . [doctor] and that was before we started the progesterone . [patient] yes . [doctor] so i know we started it for regulating your periods , but perhaps it helped with this also . [patient] yeah . and before , in november and december , i noticed that the week before my period , my anxiety would go through the roof . which then , i knew my period was coming . then it turned into my anxiety spiking just at random times . [doctor] hmm , okay . [patient] and it seemed like it was for no reason . [doctor] but november and december you were on the progesterone at that time . [patient] yes . [doctor] all right . so not really a link there , all right . [patient] yeah , i do n't know . [doctor] yeah , i do n't know either . um , sometimes with the aging process , that can happen too . [patient] i figured maybe that's what it was . [doctor] and we did go through the golive in november and december , so that can be pretty stressful also . [patient] yeah , and at work , that's when i first started to lead the process of delivering the results to patients with covid . in the beginning of the whole pandemic , patients would have to wait nine days before they'd get their results . and then we opened the evaluation centers and the covid clinic . so i think it just took a toll on me . [doctor] yeah , i can absolutely see that . [patient] yeah , and then i was feeling selfish because i was n't even on the front lines . i mean , i was supporting people , sure , but i was n't in the icu . so i felt selfish and guilty . i mean , hands down , the physicians and nurses were in the thick of it and there i was , having anxiety . and it felt ridiculous . [doctor] well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ? [patient] no . [doctor] have you lost weight ? [patient] no , but i stopped taking the camila birth control . my hunger level was at a new high . i mean , i was eating constantly . i felt like , " what is going on ? " [doctor] all right . [patient] and now i am feeling better . [doctor] okay , that's good . and your masked face , though , it does look thinner . [patient] well , the past six months i have lost some weight . [doctor] okay , good . um , anything else going on ? [patient] no . [doctor] all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ? [patient] not with you , but i did around 2009 , and then i had to be seen every six months for a while . and then i had a normal pap . [doctor] all right , well , let's just repeat it then . [patient] yeah , that's fine with me , to be safe . [doctor] okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check . [patient] okay . i fight the vaccine fight every day at home because my husband is n't ready to get it . same with my daughter . she shares the same worries as her dad in how it'll impact her when she gets older . [doctor] have you had the vaccine ? [patient] yes , i have . and so has my son . he , um , has had his first already . [doctor] okay . well , you know , you can only do what you can do . [patient] yeah , i agree . [doctor] all right . well , let's complete your exam . [patient] all right . [doctor] so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps . [patient] yeah , but they're not as big as they were . [doctor] mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ? [patient] it does , where your left hand just was . [doctor] okay , right here ? [patient] yeah , down here . but whenever i breastfed , it was always sore there too . i had a clog and something else . the lumps do feel smaller , but they are still there , unfortunately . [doctor] yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away . [patient] yeah . [doctor] all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ? [patient] yes , and i actually need to get that refilled for the first time ever . [doctor] okay . [patient] uh , but yeah , i use it once a week and it does help . [doctor] okay , great . all right , looks good . [patient] good . [doctor] you can go ahead and sit up . [patient] thank you . [doctor] all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now . [patient] okay . and what could that mean ? [doctor] well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign . [patient] and i'm- i'm just worried because i'm almost 40 and my mom was almost 45 when she was diagnosed with breast cancer . so i mean , i know there's nothing i can do about it , but it's just i feel like , uh , we had it under control and now it is n't . [doctor] well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed . [patient] yeah . [doctor] so those are all good things . [patient] okay . [doctor] because , um , if it was cancer , we'd actually , we would see some change . [patient] we would ? okay , thank you for explaining that . [doctor] yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them . [patient] yeah , i agree there . [doctor] um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it . [patient] okay . i'll do whatever you think i should . [doctor] all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule . [patient] okay , i think that sounds great . [doctor] all right . i do too . all right , well any questions or anything else we can discuss today ? [patient] no , i think i'm all set . [doctor] all right , good . all right , well have a good rest of your day and just give us a call if you need anything else . [patient] all right , thank you . you have a good day too . [doctor] all right .

CHIEF COMPLAINT Follow-up bilateral breast cysts. HISTORY OF PRESENT ILLNESS Donna Torres is a 40-year-old female who presents for follow-up surveillance of bilateral breast cysts. The patient reports continual presence of “lumps” in bilateral breasts with some soreness. She is being seen today for surveillance of the cysts. The patient is taking progesterone, which was initially prescribed to support normalization of menstruation, which was effective. She is also still using vaginal cream one time per week which has improved symptoms of itching and discomfort. Her last pap smear was in 2019, with negative/negative results. She did have an abnormal pap smear in 2009, which resulted in repeat pap smears per 6 months until her results normalized. Mrs. Torres experienced increased anxiety in 11/2021 and 12/2021, stating “it was brutal” and felt she could not manage her symptoms and sought treatment. Dr. Brown started the patient on Buspar, which has successfully controlled her anxiety. The patient relates her anxiety to work related stress and possibly aging. Her work involves supporting Covid evaluation centers and clinics. She confirms receiving both Covid vaccinations. Initially, she was experiencing spikes in anxiety prior to menstruation, but her anxiety then became more random with an unclear cause. To note, the patient was started on Singulair, which the patient was told could also cause anxiety. The patient discontinued Camila birth control, which did result in a significant increase in appetite. This has resolved and she reports she has lost weight in the past 6 months. Gynecologic History Last pap smear: 2019. History of abnormal pap smear: 2009. PAST HISTORY Medical Bilateral breast cysts. Anxiety. SOCIAL HISTORY Employed in healthcare, supports Covid evaluation centers and clinics. FAMILY HISTORY Mother, deceased age 45, from complications of breast cancer. CURRENT MEDICATIONS Buspar. Singulair. PHYSICAL EXAM Genitourinary Breast: Breast density. ASSESSMENT • Follow-up bilateral breast cysts. • Pap smear. PLAN Follow-up bilateral breast cysts Physical exam indicated stable breast density bilaterally. The patient is being seen regularly for monitoring. The plan is to continue close monitoring and the patient will be referred to breast specialist for additional review. The patient agreed to this plan. Pap smear Exam was normal. No additional treatment needed at this time. INSTRUCTIONS Schedule appointment with breast specialist. Call clinic with any additional concerns.

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D2N031

[doctor] sophia brown . date of birth , 3/17/1946 . this is a new patient visit . she's here to establish care for a history of dcis . we'll go over the history with the patient . [doctor] hello , ms. brown . [patient] hi . yes , that's me . [doctor] wonderful . i'm doctor stewart . it's lovely to meet you . [patient] you as well . [doctor] so , you've come to see me today because you had a right breast lumpectomy last year . is that right ? [patient] yes . on january 20th , 2020 . [doctor] okay . and how have you been since then ? any problems or concerns ? [patient] no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since . [doctor] perfect . i want to back up and go over your history so i can make sure everything in your chart is correct and i do n't miss anything . so , i'll tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing . sound good ? [patient] sounds good . [doctor] great . so , i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram , or was it done because you felt a lump ? [patient] it was just a normal one you're supposed to get every so often . [doctor] i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters . [patient] yes , that sounds right . hard to remember now , though . [doctor] yep , definitely . [doctor] based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5th , 2019 . pathology results during that biopsy came back as grade two , er positive , pr positive , dcis , or ductal carcinoma in situ . [patient] yes . unfortunately . [doctor] i know . scary stuff . but you had a lumpectomy on january 20th , 2020 , which removed the eight millimeter tumor and margins were negative . the pathology confirmed dcis . looks like they also removed 5 lymph nodes , which , thankfully , were negative for malignancy . that's great ! [patient] yeah , i was definitely very relieved . [doctor] and your last mammogram was in january 2021 ? and that was normal . [patient] yes . [doctor] okay . so , i feel like i have a good grasp of what's been going on with you now . and you're here today to establish care with me so i can continue to follow you and make sure you're doing well , right ? [patient] yes . fingers crossed . [doctor] definitely . we'll keep a close eye on you and take good care of you . [patient] okay , sounds good . [doctor] i have a few more questions for you . when was your last colonoscopy ? [patient] i had one in 2018 and , if i remember correctly , i had one polyp and that was removed and it was n't cancerous . [doctor] okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular adenoma . okay . and when was your last menstrual period ? [patient] gosh . it was probably around 30 years ago . [doctor] okay . do you have children ? [patient] i do . i have five . [doctor] ah , big family then . that's nice . [patient] yes . and they're all having kids of their own now , so it's getting even bigger . [doctor] i bet . sounds like fun . [patient] it is . [doctor] did you have any other pregnancies that were miscarriages or terminations ? [patient] really , i did not . [doctor] okay . so for the record , that's g5 p5 . and now that you're post-menopausal , are you currently or have you ever been on hormone replacement therapy ? [patient] my primary care doctor gave me the option years ago but i decided against it . [doctor] okay . and on your review systems form , you indicated that you've not had any recent weight loss or gain , headaches , bone pain , urinary symptoms , or blood in the stools . but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those . [patient] okay . so i've seen doctors for all of those . they've said , excuse me , the back and knee pain are age-related . and the cholesterol is a fairly new diagnosis , but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication . [doctor] okay . and your primary care doctor is following you for that , right ? [patient] that's correct . [doctor] okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ? [patient] yes , and that's all . [doctor] okay . so for your medical history , it's high cholesterol and stage 0 er/pr positive invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ? [patient] i did have my tubes tied after my last baby , but that's all . [doctor] okay . and how about family history ? [patient] my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it . [doctor] all right . any family history of breast cancer ? [patient] none . [doctor] did any of your children have medical issues or siblings with medical problems ? [patient] i do not have any siblings and , thankfully , my children are all healthy . [doctor] wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ? [patient] no drugs . i do drink socially , but never more than that . and i used to smoke , but really , everybody did back then and i probably quit about 30 years ago . [doctor] excellent . i have that you're allergic to penicillin . any other allergies ? [patient] nope , just penicillin . [doctor] okay . i think that covers it . hop up here and let me take a look at you . [doctor] okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes . [doctor] in the result section , note that her ecog performance status today is zero . [doctor] do you have ... did you have radiation after the lumpectomy ? [patient] i did . we also talked about endocrine therapy , but i decided against that . [doctor] okay . so your exam looks good , no masses , just some skin changes from that radiation . now , let's go over the plan for you . [patient] okay , sounds good . [doctor] as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy . [doctor] so , based on all of that , we can just continue to observe you . [patient] okay . that sounds great . and when do i come back in to see you ? [doctor] in a year , but you should have another mammogram in april of 2022 before you come back to see me . [patient] okay , i can do that . [doctor] wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ? [patient] i do n't think so . [doctor] okay , great . my nurse will be in shortly to discharge you . take care ! [patient] you as well .

CHIEF COMPLAINT History of right ductal carcinoma in situ (DCIS). HISTORY OF PRESENT ILLNESS Sophia Brown is a 75 y.o. female who presents today for a new patient evaluation due to her history of right DCIS. She is doing well but wishes to establish care today for continued monitoring. The patient underwent a screening mammogram in 10/2019 and was found to have a calcification in the right breast. She then had a right breast ultrasound on 11/03/2019 which revealed a mass at the 2 o’clock position, 11 cm from the nipple, in the retroareolar region. The report states the mass was 0.4 by 2.0 by 3.0 centimeters. She subsequently had an ultrasound-guided core needle biopsy on 12/05/2019 and pathology results revealed grade 2 ER-positive, PR-positive DCIS. The patient then had a lumpectomy with lymphadenectomy performed on 01/20/2020. The tumor was 8 mm with negative margins and the 5 lymph nodes removed were all benign. Pathology from the tumor confirmed DCIS. Her lumpectomy was followed by adjuvant radiation therapy. Endocrine therapy was also offered but the patient declined. She has since had a mammogram in 01/2021 which was normal. The patient also reports that she performs self-breast exams regularly at home. Mrs. Brown is a G5P5 female and estimates that her last menstrual period was approximately 30 years ago. She is not currently and has never been on hormone replacement therapy. The patient’s last colonoscopy was done in 2018. She had a sigmoid polypectomy at that time and pathology showed a tubular adenoma. Her cholesterol was recently noted to be elevated and the patient reports that she is exercising and reducing fatty food intake accordingly. This is being followed by her primary care provider. PAST HISTORY Medical Hypercholesterolemia. Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast, status post lumpectomy and adjuvant radiation therapy. Surgical Right lumpectomy, lymphadenectomy x5, 01/20/2020. Bilateral tubal ligation. SOCIAL HISTORY Alcohol: Socially. No history of heavier consumption. Illicit drug use: Never. Tobacco: Former smoker. Quit approximately 30 years ago. Patient has 5 children and multiple grandchildren. FAMILY HISTORY Mother: Non-Hodgkin’s lymphoma. Father: Prostate cancer, heart disease. Her children are healthy. She has no siblings. Denies family history of breast cancer. CURRENT MEDICATIONS Co-Q 10. Vitamin D. Vitamin C. Fish oil. Elderberry fruit. ALLERGIES Penicillin. REVIEW OF SYSTEMS Negative for weight loss, weight gain, headaches, bone pain, urinary symptoms, blood in the stools. Positive for back pain, joint pain, high cholesterol. Patient has sought care for these complaints. She reports that she was told the back pain and joint pain (knee) are age-related. She is being followed for the high cholesterol by her primary care provider. PHYSICAL EXAM The ECOG performance status today is grade 0. Breast: There are no palpable masses; however, there is some skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes. ASSESSMENT Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast. The patient is status post lumpectomy with removal of 5 lymph nodes which were benign. She also underwent adjuvant radiation therapy but declined endocrine therapy. Today’s clinical examination shows no evidence of recurrent disease or other malignancy. She also had a negative mammogram in 01/2021. PLAN 1. We will continue to observe the patient. 2. She is due for a mammogram in 04/2022. 3. She should follow up with me in 1 year after the mammogram.

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D2N032

[doctor] good morning ms. reyes ! [patient] good morning . [doctor] how are you doing ma'am ? [patient] i'm doing well doctor , how are you ? [doctor] i am fine thank you . so you've been having some problems with your right hip ? [patient] yeah . [doctor] okay , and where are you hurting ? can you show me ? [patient] right in the groin area . [doctor] okay , and this has been going on since february 2020 ? [patient] yeah . [doctor] okay . and is it worse with movement ? [patient] well when it catches and i almost fall , yeah . [doctor] okay . so it kinda grabs you ? [patient] yeah . [doctor] okay , and this all started when you were walking ? [patient] well , walking around the infusion room . [doctor] okay . [patient] so it started if i took a step back or , you know , stuff like that . now it happens anywhere . [doctor] okay , so now it hurts whenever you move ? [patient] it hurts when i pivot . [doctor] okay . so if you pivot then it hurts , got it . um ... [patient] anything can sometimes do it . sometimes it wo n't though , and sometimes it'll do it several times in a row . [doctor] several times in a row , okay . [patient] and sometimes i fall . [doctor] okay . and you rate the pain to range from two through seven out of 10 ? [patient] yeah , that's correct . [doctor] okay . and are you experiencing fever or chills ? [patient] no . [doctor] okay . and any tingling or numbness ? [patient] no . [doctor] and have you had any problems with your bowel or bladder ? [patient] no . [doctor] okay . and if you stay still , do you feel better ? [patient] yes , but i do n't want to stay still . [doctor] i understand , no problem . and for past medical history , do you have anything going on ? [patient] i've had a lot of surgeries . i've had pcl , i had infertility , a gall bladder removed , but that's it . [doctor] okay . and for family history , it looks like there's high blood pressure , diabetes , thyroid disease , heart disease , kidney disease and gastric ulcers . for your current medications , it does n't look like you're taking anything at this time . and you're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ? [patient] yes , i've lost 110 pounds . [doctor] that is awesome . and how did you do that ? [patient] with weight watchers . [doctor] that's great . [patient] mm-hmm . [doctor] and how many months have you been participating in weight watchers ? [patient] i started in 2018 , and i've been at my current weight for a little over a year . [doctor] that is awesome . [patient] yeah , thank you . [doctor] yeah , very good , and congratulations . and so , for social history , it looks like you work at an infusion center ? [patient] yes , over at . [doctor] okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month . [patient] that's correct . [doctor] all right . well let's go ahead and take a look at your hip . [patient] okay . [doctor] please use my general physical exam template . physical exam . ms. reyes is a pleasant 56-year-old woman who is five feet , six inches in height , weighing 169 pounds . blood pressure is 115 over 75 . pulse rate is 67 . ankles , no ankle edema is noted , no calf tenderness . okay , ms. reyes , can you go ahead and stand up for me please and take a couple of steps ? great . [patient] okay . [doctor] and can you walk on your tippy toes ? good , okay . and can you walk on your heels ? kind of a heel walk and toe walk are intact . um , go ahead and turn around please . [patient] okay . [doctor] examination of the cervical spine , any pain here now ? [patient] no . [doctor] okay , no tenderness . look at your right and your left and then over to the right , then go ahead and look up , then look down , and look straight ahead . range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ? [patient] no . [doctor] okay . skin is intact , no midline tenderness to palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ? [patient] no . [doctor] okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ? [patient] no . i did or do have several bulging discs . [doctor] okay . but you're not hurting right now ? [patient] no , the weight loss has really decreased all the pain . [doctor] okay . range of motion is decreased in exertion . lateral flection without pain . any pain when i push ? [patient] no . [doctor] okay . you can go ahead and , um , sit down please . no pain ? [patient] no . [doctor] okay . sacroiliac signs are negative . examination of the hips . trochanteric is non tender . go ahead and lift your knee up , does that bother you ? [patient] um , just a little bit . [doctor] okay , little bit . and then back one , probably bothers you ? [patient] right there , like there , yeah . [doctor] okay . how about this way ? not too bad ? [patient] no . [doctor] okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . okay , go ahead and keep it up , do n't let me push it down . does that hurt ? [patient] right there . [doctor] okay . resisted right hip flection causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ? [patient] yeah . [doctor] okay . motor control is normal in the lower extremities . go ahead and lift your knee up . [patient] okay . [doctor] okay , lift it up . any pain ? [patient] no . [doctor] okay . and this one ? [patient] yeah . [doctor] and squeeze your knees together , push it out and kick your leg out straight . now go ahead and bring it back and kick it out straight again . and go ahead and lean back , keep it loose . okay , all set . you can go ahead and sit up now . [patient] okay , thank you . [doctor] you're welcome . so what i think we're dealing with is right hip degenerative joint disease . [patient] okay . [doctor] and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort , as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain . [patient] hmm , i do n't love that idea but i'll give it a try . [doctor] okay , that would be great . and we can also try a cortisone injection into the right hip joint to see if that offers any relief . [patient] i would like to definitely get the injection . [doctor] okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed . [patient] okay , that sounds good . [doctor] okay . and here are the risks associated with getting the inje- injection . um , please just take a moment to review it and consent to the shot . [patient] i'm good . [doctor] great . we'll get that set up for ya . all right , well i hope things , um , feel better , and we will see you back here in three months . [patient] see you . have a nice day . [doctor] thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile and covid . she understood and decided to proceed with the injection . she will follow up with me in three months for another injection if needed . end of dictation .

CHIEF COMPLAINT Right hip pain. HISTORY OF PRESENT ILLNESS Elizabeth Reyes is a 56-year-old female who presents for the evaluation of pain in her right hip and groin region. Her symptoms started on 02/2020 and has progressively worsened. She is employed as an RN and notes that her symptoms began while she was working and walking around the infusion room at Johnson. Initially the pain would only happen when she took a step back, but the pain has progressed and now occurs with any type of movement involving her right hip and groin. She describes that her hip will sometimes “catch” when she moves, causing her to fall on occasion. The pain improves when she is still and stops moving. She rates her pain as 2-7/10. Starting in 2018, the patient intentionally lost 110 pounds through Weight Watchers. She has maintained the weight loss and her weight has been stabile for the past 1 year. She has a history of several bulging discs, but the pain has significantly reduced due to her weight loss. Today, she reports no back pain. She denies fever, chills, new onset of bowel or bladder dysfunction, tingling or numbness. Opioid Assessment Opioid Use: No. Pain Assessment Pain is frequent. Quality of Pain: Right hip catches. Intensity of Pain Using VAS 0-10 Scale (0 = No pain, 10 = Worst imaginable pain) • Current Pain Intensity: 2/10. • Average Pain Intensity Over the Past Week: 4/10. • Pain at Best: 2/10. • Pain at Worst: 7/10. Relieving Factors: Lying down, sitting. Aggravating Factors: Walking, pivoting, turning, any movement engaging right hip. PAST HISTORY Medical PCOS. Surgical Cholecystectomy. SOCIAL HISTORY Works at the infusion center at Johnson. Lives with a roommate. Denies tobacco use. Limits alcohol intake to less than 5 drinks per month. FAMILY HISTORY Hypertension. Diabetes. Thyroid disease. Kidney disease. Gastric ulcers. CURRENT MEDICATIONS NSAID PRN by mouth. ALLERGIES Percocet. Vicodin. Reglan. VITALS Blood pressure: 115/75 Pulse: 67. Height: 5’6. Weight: 169 lb. PHYSICAL EXAM Constitutional Pleasant. Integumentary Skin is in tact. Musculoskeletal Extremities: No bilateral ankle edema or calf tenderness. Examination of gait: Heel-walk and toe-walk are intact. Cervical spine exam: No tenderness is elicited. Range of motion is full in all planes without pain. Spurling's test is negative. Lumbar spine exam: Range of motion is decreased in extension and lateral flexion without pain. No tenderness is elicited in the midline. Sacroiliac joint exam: Bilateral sacroiliac joints are nontender to palpation. Bilateral hip exam: Range of motion is decreased in the right hip with pain in the groin on internal and external rotation. Resisted right hip flexion causes pain in the right groin region. Bilateral trochanteric regions are nontender to palpation. Neurological Motor bulk and tone are normal in both lower extremities. Motor strength testing reveals no focal motor weakness in the lower extremities. Deep tendon reflexes are 1+ throughout. No focal sensory deficit is noted. RESULTS MR arthrogram of the right hip completed on 06/03/2021 reveals evidence of high-grade chondromalacia involving the anterosuperior right acetabulum with subchondral marrow edema and cyst formation. ASSESSMENT • Right hip degenerative joint disease. PLAN I discussed the clinical and radiological findings with the patient. Treatment options discussed are low impact exercises, use of analgesics as needed, and use of a cane to offload the right hip. She would like to proceed with a cortisone injection into her right hip joint. We will administer the injection today. I reviewed the procedure in detail, including the risks of the injection related to the use of steroid in the COVID setting. She understands the risks and would like to proceed with the injection. INSTRUCTIONS Schedule a follow up appointment in 3 months to assess her pain. If needed, a second injection may be administered.

aci

D2N033

[doctor] so sophia i see that you you hurt your knee tell me about what happened [patient] yeah i was jumping on my kid's trampoline and i could just slipped out from under me [doctor] my gosh one of those big trampolines in your back yard [patient] yeah a pretty big one [doctor] okay which knee was it [patient] my right knee [doctor] right knee okay and when did this happen [patient] about four days ago [doctor] great the weather was perfect this weekend so i'm glad you at least got outside sorry to hear you got hurt okay so your right knee did you did you feel it like pop or or snap or anything when you hurt it [patient] yeah i felt a little pop and then it swelled up really big afterward [doctor] okay did you try anything for the pain [patient] i took some ibuprofen and i put some ice on it [doctor] okay did that help [patient] a little bit but it's still really hard to get around [doctor] alright and have you have you been able to stand on it or does that hurt too much [patient] it hurts quite a bit to stand but i am able to put weight on it [doctor] okay alright and what part of the knee is it inside outside middle [patient] kind of that inside part of my kneecap [doctor] okay alright and okay so as long as you're here and then your primary care physician i'm looking through your chart and it looks like we're treating your diabetes so how you've been doing with your your diet overall are you are you keeping your sugars low [patient] it's going okay i i forget to check quite a bit though [doctor] sure [patient] on it [doctor] yeah i understand how has your diet been lately [patient] it's been pretty good [doctor] okay okay good good you know it's hard to stay away from the sugary foods sometimes i i enjoy ice cream regularly okay so let's do physical exam as long as you are here so i'm just gon na listen to your heart your heart sounds normal no murmurs or gallops listen to your lungs quick if you can take a deep breath lungs are clear that's good news let's take a look at that knee right knee looks like it definitely has some swelling i'm gon na do some maneuvers here does it hurt when i push you on the inside of the knee [patient] yeah that hurts [doctor] okay how about the outside [patient] a little bit but not as much [doctor] okay so some pain on palpation on the inside little bit of pain on the outside of the knee if i bend the knee back does that hurt [patient] yeah [doctor] how about when i extend it [patient] yeah that hurts [doctor] okay so little bit of limited range of motion as well as pain on both flexion and extension on the knee i'm gon na push on this a little bit looks like your mcmurray's test is negative just checking for a meniscus tear okay so let's talk a little bit about your plan what i am concerned about for your knee is it sounds like you have a torn or injured mcl i it's that inside tendon in your knee so i'm concerned about that since you're having trouble with weightbearing and you heard that pop so what i'm gon na do is i'm gon na put you in a straight leg brace and i'll prescribe some mobic you can start taking that as a a pain reliever and to try to get some of the swelling down i want you to ice your knee once an hour for about fifteen minutes but i'm also gon na send you out for an mri because we wan na make sure this is what happens see if there's any other damage to the knee does that sound good [patient] yeah that sounds great thank you [doctor] yeah and then for your diabetes as long as you're here it sounds like you're managing that pretty well but i do wan na get a recheck on your hemoglobin a1c and then i'm also i'm going to get a refill on the metformin that you have been taking five hundred milligrams so you can keep taking that as well so do you have any other questions for me [patient] no that's it thanks [doctor] alright well thank you hope that you feel better

CHIEF COMPLAINT Right knee pain. MEDICAL HISTORY The patient has a history of diabetes. She has been doing pretty good with her diet. She states that she forgets to check her sugars quite a bit. REVIEW OF SYSTEMS Musculoskeletal: Reports right knee pain and swelling. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular No murmurs, gallops. Musculoskeletal - Examination of the right knee: Some swelling present. - Palpation: Some pain to palpation on the medial aspect of the right knee, and a little bit of pain on the lateral aspect of the right knee. - Range of Motion: Limited range of motion as well as pain on both flexion and extension of the knee. - Special Testing: McMurray's Test: Negative. ASSESSMENT AND PLAN 1. Right knee pain. - Medical Reasoning: I am concerned about a torn MCL due to pain on ambulation and trouble with weightbearing, as well as the pop she heard. - Patient Education and Counseling: We discussed treatment options today including bracing, anti-inflammatories, and icing. - Medical Treatment: I am going to put her in a straight leg brace and I will prescribe some Mobic. She can start taking that as a pain reliever and to try to get some of the swelling down. I want her to ice her knee once an hour for about 15 minutes. - Additional Testing: I am also going to send her out for an MRI. 2. Type 2 diabetes. - Medical Reasoning: The patient states that her type 2 diabetes are well-managed. - Medical Treatment: I am also going to get a refill on the metformin that she has been taking 500 mg. - Additional Testing: We are going to recheck her hemoglobin A1c. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

aci

D2N034

[doctor] alright you can go ahead [patient] hey alan i good to see you today so i looked here my appointment notes and i see that you're coming in you had some shoulder pain left shoulder pain for the last three weeks so [doctor] how you doing is it is it gotten any better [patient] yeah yeah i've been having a lot of pain of my shoulder for the last three weeks now and it's not getting better okay do you remember what you were doing when the pain first started [doctor] so i i was thinking that i i ca n't recall like falling on it injuring it getting hit [patient] hmmm [doctor] i have been doing a lot of work in my basement and i even i put in a new ceiling so i do n't know if it's from all that activity doing that but otherwise that's that's all i can think of [patient] okay so do you remember hitting it or anything like that [doctor] no nothing at all [patient] okay alright did you fall do you remember doing that [doctor] no [patient] okay hmmm so like a little mystery so have you had pain in that shoulder before [doctor] i mean i'm very active so i can get pains in my shoulders but it's nothing that sometime some tylenol can help [patient] okay and are you able to move the arm or is it kinda just stuck [doctor] i'm having a lot of pain like i can move it but you know when i try to reach for something lifting anything and even like i do n't even try to put my hands over my head because it causes so much pain [patient] alright so does that pain radiate anywhere or like where would you say it is in your shoulder [doctor] it actually it stays pretty much just right at the shoulder it does n't go down anywhere [patient] okay and the pain is it is it all the time or does it come and go [doctor] it's pretty much all the time anytime i put any pressure on it like when i'm trying to sleep it hurts even more so it's been affecting my sleep as well [patient] okay so i know you mentioned tylenol so this time i have n't taken anything for it [doctor] yeah i i do the tylenol which usually works for me and it does take the edge off but i still have pain okay did you try icing it at all [patient] i iced it initially but i have n't iced it at all recently [doctor] alright [patient] and so with your shoulder have you experienced any numbness in your arm or in your fingers [doctor] no numbness or tingling [patient] okay good so i'm gon na go ahead and do a quick physical exam and take a look at your your shoulder so i reviewed your your vitals everything looks good with that so touch here in your shoulder so your left shoulder exam you have limited active and passive range of motion so pressure here so that there is tenderness of the greater [doctor] okay [patient] tuberosity of the humerus let's see there is no tenderness at the sternoclavicular or acro [doctor] yeah [patient] acromioclavicular joints [doctor] yeah yeah [patient] and looks like you have good hand grip let me see so on the neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is is intact to light touch [doctor] yes thank you yep [patient] so you did get a we get we had to get a x-ray of your shoulder before you came in and so it's normal so that's really good so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you you do have that left shoulder pain so your symptoms are [doctor] most likely due to a rotator cuff tendinopathy so this means that you injured tendon you have injured tendons and muscles that make up your shoulder and make up your shoulder muscles so what i'm gon na do is i'm gon na order an mri of your left shoulder [patient] and so we're gon na begin with that just to make sure nothing else is going on have you done physical therapy before [doctor] i have n't [patient] okay so what i'm gon na do i'm going to refer you to physical therapy for approximately six to eight weeks and so they can help you strengthen those muscles around your shoulder and that should definitely help with the pain during that time you can also continue to take tylenol i do n't think i need to prescribe anything else for the pain you said as it's working pretty good for you so if your symptoms do n't improve we can consider a steroid injection of your shoulder which should provide some relief but i think right now we can just go with the the pt and hopefully that works to alleviate your injury so do you have any questions about the plan [doctor] so like i said i'm really active do you think that this pain will ever go away [patient] yeah so many patients are very successful with rehab and so we'll start with that and see how you do most most of the time once we build up those muscles around that shoulder you know things things the pain alleviates itself and and and you will be good to go back to working on your basement and running and jogging and lifting weights all all the active things people do these days [doctor] okay alright thank you [patient] bye [doctor] okay bye

CHIEF COMPLAINT Left shoulder pain. HISTORY OF PRESENT ILLNESS Alan Mitchell is a pleasant 69-year-old male who presents to the clinic today for the evaluation of left shoulder pain. The onset of his pain began 3 weeks ago, without any improvement. He denies any specific injury; however, he has been renovating his basement and putting in a new ceiling. He does not recall hitting or falling onto the left shoulder. The patient states he is very active and has experienced left shoulder pain before that usually resolves with Tylenol. The patient reports significant pain with reaching, lifting, and overhead activities. The pain is constant. He states the pain is primarily located in the left shoulder and denies it radiates down into the left arm. The patient also reports difficulty sleeping secondary to the pain. He denies any numbness or tingling in his left arm or fingers. He has been taking Tylenol for pain, which provides partial relief. He initially iced his shoulder but has not iced it recently. The patient denies he has done any physical therapy. REVIEW OF SYSTEMS Musculoskeletal: Reports left shoulder pain. Neurological: Denies numbness or tingling. VITALS All vital signs are within the normal limits. PHYSICAL EXAM MSK: Examination of the left shoulder: Limited active and passive ROM. Tenderness over the greater tuberosity of the humerus. No tenderness at the sternoclavicular or AC joints. Good hand grip. Neurovascularly intact distally. Capillary refill is less than 3 seconds. Sensation is intact to light touch distally. RESULTS X-rays of the left shoulder were obtained and reviewed today. These are normal and reveal no fracture or bony abnormalities. ASSESSMENT Left shoulder pain, likely rotator cuff tendinopathy. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding his current symptoms. I have explained that his x-rays did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the left shoulder to evaluate for possible rotator cuff tendinopathy. The patient was provided with a referral to formal physical therapy. He will engage in a 6-to-8-week course in order to strengthen his left shoulder. I have also advised him to take Tylenol as needed for pain. If his symptoms do not improve, we may consider a steroid injection to the left shoulder. INSTRUCTIONS The patient will follow up with me once the MRI results are available for review and further discussion.

aci

D2N035

[doctor] well hello christina so how are you doing i was notified you were in the hospital for some heart failure what happened [patient] well i'm doing better now but i just started having problems that my ankles were swelling and could n't get them to go down even when i went to bed and could n't breathe very good had to get propped up in bed so i could breathe at night and so i just really got to feeling bad i called my friend diane and she said i probably ought to call nine one one since i was having a hard time talking and so i called nine one one and they sent out an ambulance and they took me into the er on the it was quite an experience [doctor] yeah [patient] having an ambulance ride and and i've never done that before so not an experience i wan na do again either [doctor] i'm sure you do n't yeah i see that your blood pressure was high also it was two hundred over ninety have you been [patient] yeah i guess is that really high [doctor] yeah that's [patient] i feel really bad [doctor] yeah that's pretty high are you taking your medications or you missing some doses [patient] i do n't know i might miss one now but i try to take them all time [doctor] yeah yeah you really need to take them very consistently now you also said you were watching your diet did you did you have some slips with that you said your ankles were swelling [patient] no i yeah i do i like to i like to eat [doctor] are you eating a lot of salty foods and pizza or [patient] i like potato chips [doctor] yeah [patient] i like the salt and vinegar potato chips they're really good so [doctor] well so do you do you go out to eat a lot or do you where you where where are you eating those potato chips or is that just the home snacking or [patient] that's home snacking i buy the the the the brand name salt and vinitive because brand wo n't taste real good but the the brand names really tastes good [doctor] oh [patient] so i eat those probably everyday [doctor] goodness well you know you we need to probably stop eating those now [patient] yeah well i hate to hate to give those up but i guess i might have to [doctor] well since you've been in the hospital and and they've helped you out with some with all that how are you feeling now [patient] well i'm i'm doing better [doctor] mm-hmm and they [patient] i do n't do n't have quite as much shortness of breath i think maybe getting up and walking a little more is helping [doctor] and they gave you a water pill and is that is that helping is that making you pee a lot [patient] yeah yeah i have almost incontinence so [doctor] goodness [patient] yes that's not very pleasant at all [doctor] and so they added another blood pressure medication also how are you doing with that are you feeling a little bit better [patient] yeah i think so [doctor] okay [patient] if i can remember to take the pills [doctor] yeah [patient] that seems to be a sticky point [doctor] well a a pill box or maybe setting an alarm on your phone might really help [patient] okay i'll i'll give that a try anything that will help [doctor] yeah okay well that's good to hear so now have you bought a blood pressure cuff to have at home now [patient] yes i already had one but i very failed if i ever used it [doctor] okay [patient] but [doctor] got it [patient] i'll i'll try to use it everyday now [doctor] okay and you might even just keep a log of what your blood pressures are and when it's up think about you know what you've eaten if you've done something different because that may help you to figure out what you need to cut back on or how you might need to change your your eating habits a little bit so [patient] okay okay [doctor] have you been short of breath or any problems sleeping since you've been home [patient] no i've been sleeping like a log [doctor] okay good alright have you had any chest pain [patient] no no chest pain [doctor] okay alright well let's do a quick physical exam here so your vital signs your blood pressure looks pretty good today at one twenty eight over seventy two your temperature is ninety eight . seven and your heart rate is seventy two your respirations are eighteen your oxygen saturation looks pretty good at at ninety six percent okay now on your neck exam there is no jugular venous distention on your heart exam i appreciate a two over six systolic ejection murmur which i've heard before and so it's stable and your lungs are clear bilaterally and your lower extremities show just trace edema now now we since we did the echocardiogram i reviewed those results and it does show a preserved ef of fifty five percent abnormal diastolic filling and mild-to-moderate mitral regurgitation so let me tell you a little bit about my assessment and plan so for your first problem for your congestive heart failure it sounds like this was caused by dietary indiscretion and some uncontrolled hypertension so i want you to continue on your bumex two milligrams once daily continue to watch your diet and avoid salty foods might try keeping that log we talked about with your blood pressures and what you've eaten if if your blood pressure seems a little high also weigh yourself daily and call me if you gain three pounds in two days okay [patient] okay [doctor] and i also want you to see a nutritionist to give you some education about what foods you can eat okay now for your second problem for i know this sounds like this is just for you and so for your second problem for your hypertension i want you to continue on the cozaar one hundred milligrams daily continue on the norvasc five milligrams once daily also and i'm going to order a renal artery ultrasound just to be sure we're not missing anything and then like maybe you know some renal artery stenosis or something and so so for your third problem for your kidney disease i wan na get some more labs to make sure you tolerate this the new medications and then i'll see you again in three months do you have any questions [patient] no i do n't think so not today [doctor] alright it's good to see you and i hope we'll just keep getting you feeling better [patient] okay

CHIEF COMPLAINT Emergency department follow up. MEDICAL HISTORY Patient reports history of hypertension. MEDICATIONS Patient reports taking Bumex 2 mg once daily, Cozaar 100 mg daily, and Norvasc 5 mg once daily. REVIEW OF SYSTEMS Constitutional: Denies sleep disturbance. Cardiovascular: Denies chest pain. Respiratory: Denies dyspnea. Genitourinary: Reports urinary incontinence in the setting of diuretic medication. VITALS Blood Pressure: 128/72 mmHg Temperature: 98.7 degrees F Heart Rate: 72 bpm Oxygen Saturation: 96% PHYSICAL EXAM Neck - General Examination: No jugular venous distention. Cardiovascular - Auscultation of Heart: Stable 2/6 systolic ejection murmur. Musculoskeletal - Examination: Trace lower extremity edema. RESULTS Echocardiogram reveals a preserved ejection fraction of 55%, abnormal diastolic filling, and mild-to-moderate mitral regurgitation. ASSESSMENT AND PLAN 1. Congestive heart failure. - Medical Reasoning: This appears to have been caused by dietary indiscretion and uncontrolled hypertension. - Patient Education and Counseling: I encouraged the patient to continue making dietary modifications, including limiting her sodium intake. She could try keeping a food diary, as previously discussed, to log her diet and associated blood pressure readings. I also advised her to monitor her weight daily and contact me if she gains 3 pounds in 2 days. - Medical Treatment: Continue with Bumex 2 mg once daily. Referral placed for consult with a nutritionist for education and recommendations regarding her diet. 2. Hypertension. - Medical Reasoning: This has been poorly controlled due to inconsistent compliance with medication and dietary indiscretion. - Patient Education and Counseling: We discussed dietary modifications as noted above. - Medical Treatment: She can continue on Cozaar 100 mg daily and Norvasc 5 mg once daily. Renal artery ultrasound ordered to rule out any issues such as renal artery stenosis. 3. Kidney disease. - Medical Treatment: Labs will be ordered to assess her response to new medications. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 3 months.

aci

D2N036

[doctor] hey george how are you today i understand you're here for some numbness and tingling in your fingers and some pain in your wrist [patient] right my right wrist and hand has been bothering me probably for a few months now with pain and numbness [doctor] okay and you said that's been ongoing for several months do you know what caused this type of pain or is it just something that started slowly or [patient] it just kinda started on it's own it i notice it mostly at night [doctor] okay [patient] sometimes it will i'll wake up and my hands asleep and i got ta shake it out [doctor] shake it out and okay [patient] and then some [doctor] what kind of work do you do [patient] i do yard work [doctor] yard work [patient] landscaping landscaping [doctor] landscaping okay so a lot of raking a lot of digging so a lot of repetitive type movements [patient] yeah it's pretty heavy labor but it's yeah the same thing day in and day out [doctor] okay okay just a couple questions for you you did say that you have the pain at night in that and you have to you get that numbness into the hand is it in all the fingers [patient] yeah it seems to happen to all my fingers but i notice it more in my thumb and pointer finger [doctor] okay okay and anything into that little into your fifth finger your little finger any numbness there at times no [patient] sometimes yeah it seems like it's numb too [doctor] okay what about your right hand any problems with that hand [patient] no i do n't seem to have any problems with my right hand so far it's just mostly my left [doctor] okay okay good and just a couple you know do you how do you have many or do you drink often do you have you know many any alcohol consumption [patient] i drink usually a a beer or two on fridays and saturdays on the weekends [doctor] okay and do you have any evidence of any anybody ever said that you had some rheumatoid arthritis in your hand or wrist anything like that [patient] no nobody say anything like that so i mean [doctor] okay okay good so let me go ahead and do a physical exam here real quick and you know i'm gon na quickly just listen to your heart and lungs okay that's good i'd like you to squeeze i'm gon na hold your hands here and i'd like you to squeeze both hands [patient] okay [doctor] you seem a little bit weaker on that left hand is that what you've noticed [patient] yeah i i i experienced some weakness in my left hand [doctor] okay do you you find that you're dropping things when you're picking it up is it to that level or [patient] yeah i drop things mostly because i have a hard time feeling it [doctor] okay okay good and so you you do have a a grip strength is less on the left and i just wan na touch your fingers here on the on the right side you can feel me touching all the fingers on the right [patient] yeah i can i can say you touch me but it feels a little more weird on the thumb side than my pointer finger side [doctor] okay okay and i wan na turn your wrist over here and turn your hand over and i'm gon na go ahead and tap on the right wrist on the back here does that do anything when i do that [patient] i still i feel a little jolt or a zing in my finger tips [doctor] okay and then when i do that on the left side [patient] yeah same thing [doctor] same thing okay so you do have a bilateral positive tinel's sign so so here's here's where i'm at i think your your diagnosis is beginning to have some bilateral carpal tunnel syndrome usually we see that with repetitive actions such as the landscaping the heavy labor and you you know your your clinical exam and and history sound like it's a carpal tunnel syndrome i do want to order so where are we gon na go from here i would like to order a a study it's called an emg where it it measures some of that electrical impulses down into your fingers we will follow up with that but as far as your treatment so the treatment for carpal tunnel syndrome is really some activity modification now i know you are a landscaper is there any way that you could be work to have some lighter work during the time [patient] i suppose i could try to pass it off to some of my other employes and delegate [doctor] okay that would be good so that's i i just want you to kinda eliminate that the active repetitive motions that you're doing all the time just for a couple weeks i'm also gon na give you a wrist splint to wear and that should help and i'd like you to take ibuprofen six hundred milligrams every six hours and then i wan na see you back here in the office in two weeks and in that two week period i think we're gon na see if there's need for any other intervention if i need to do more diagnostic testing or if there is a possibly looking at a surgical intervention to release that pressure that's on the nerves in that hand does that sound like a a good plan for you [patient] yeah it sounds like a good first start [doctor] okay okay so i i just just off off the record here what kind of what do what do you specialize in landscaping is your company do [patient] mostly like yard work and maintenance flower beds not really designing just up keep [doctor] okay yeah i'm looking for a landscape designer i need somebody to put in some elaborate walkways back through the backyard so yeah we can do stuff like that i mean if you have an idea what you want i think that's easy [patient] okay [doctor] you know if you're looking for like some [patient] backyard elasis rehab remodel that's i mean i suppose we could do we have n't done things like that in a while because we're busy enough with just the up key but it's something to explore [doctor] okay yeah i may have to keep that in mind because i do wan na do some of that so let's listen i'm gon na get my my nurse in here to discharge you do you have any other questions for me before we end this [patient] no i think it's all clear i appreciate it [doctor] okay take care and i'll look forward to see you in two weeks [patient] very good appreciate your time

CHIEF COMPLAINT Left wrist and hand pain. HISTORY OF PRESENT ILLNESS George Lewis is a pleasant 57-year-old male who presents to the clinic today for evaluation of left wrist and hand pain. He reports an onset of a few months ago but denies any specific injury. However, the patient notes he often engages in repetitive motions while performing his work duties. His symptoms are worse at night, and he wakes with numbness in the bilateral hands. He experiences numbness in all fingers, but states it is the most noticeable in the left thumb and index finger. He affirms intermittent numbness in the left little finger. For relief, he shakes his hands upon waking. The patient also experiences weakness in his left hand. He reports he drops objects and explains “I have a hard time feeling it.” MEDICAL HISTORY The patient denies a history of rheumatoid arthritis. SOCIAL HISTORY He works in landscaping. He reports consuming 1 to 2 beers on weekends. REVIEW OF SYSTEMS Musculoskeletal: Reports left wrist and hand pain. Denies right hand pain. Neurological: Reports numbness in bilateral hands and fingers, and left hand weakness. PHYSICAL EXAM NEURO: Decreased sensation in the right thumb and index finger. MSK: Examination of the bilateral hands: Grip strength is less on the left in comparison to the right. Positive Tinel sign bilaterally. ASSESSMENT Bilateral carpal tunnel syndrome. PLAN After reviewing the patient's clinical history and examination today, I have had a lengthy discussion with him regarding treatment options for his current symptoms. I discussed the importance of activity modification and encouraged the patient to limit active repetitive motions while working for the next 2 weeks. I also recommended that he wear a wrist splint to provide increased support. I advised him to take ibuprofen 600 mg every 6 hours. Additionally, I recommended we obtain an EMG of the bilateral upper extremities to evaluate for carpal tunnel syndrome. The patient will follow up with me in 2 weeks when the EMG results are available for review. If at that time his symptoms have not improved with these conservative measures, we will discuss further treatment options including additional diagnostic testing or possible surgical intervention. The patient states he understands and is in agreement with the plan. All questions were answered to the patient's satisfaction. INSTRUCTIONS The patient will follow up with me in 2 weeks.

aci

D2N037

[doctor] hey dylan what's going on so i lift quite a bit of weights i try to stay in shape as much as i can i'm not like normal people i lift heavy weights and my elbow is extremely sore which elbow is it [patient] actually it's both my elbows but my right elbow is hurting me the most [doctor] okay and you said you lift a lot of weights [patient] mm-hmm [doctor] did you play any sports when you were younger [patient] no anything you can think of primarily it was basketball baseball and football [doctor] okay and did your elbows hurt at that time or is this a a new injury [patient] it's new [doctor] when did it start [patient] probably year and a half ago [doctor] okay on both elbows about a year and a half ago [patient] yeah [doctor] okay have you taken anything for the pain [patient] ibuprofen eight hundred milligrams three times a day [doctor] okay and does anything make it better or worse [patient] the more i use my hands or my arms the more it hurts [doctor] okay have you tried icing [patient] yes [doctor] does that give you any relief [patient] no [doctor] alright is it the inside or outside of your elbows [patient] inside [doctor] inside okay let's just do a quick physical exam here i'll take a look at your right elbow first [patient] mm-hmm [doctor] if i bend it this way up does it hurt it's your left does that hurt [patient] yes [doctor] how about this [patient] yes [doctor] okay so pain with both flexion and extension [patient] mm-hmm [doctor] looks like you have little bit of limited range of motion on extension not on flexion though you said it hurts right here on the inside of your elbow [patient] yes [doctor] okay so pain on the medial side with palpation [patient] yes [doctor] alright how about the outside [patient] no [doctor] no pain with palpation outside of the elbow you have do you have normal sensation in your fingers [patient] i think so [doctor] yeah [patient] yeah [doctor] okay great [patient] good to go [doctor] sensation is normal to the touch [patient] yes [doctor] pulses equal in all extremities how about the left elbow same thing if i bend it this way does that hurt [patient] not as much [doctor] how about this way [patient] not as much [doctor] alright so little bit of pain on flexion and extension little bit of limited range of motion on extension of the arm how about if you twist like you're opening a door [patient] yes [doctor] okay so some pain with torsion and twisting supination what about pronation [patient] no [doctor] no pain with pronation on the right side [patient] mm-hmm [doctor] same thing on the left [patient] yes [doctor] pain with supination no pain with pronation [patient] correct [doctor] alright so dylan it took some x-rays coming in looks like you do n't have any any fractures or any bony misalignment which i expect with this kind of injury i do think that what you have is medial epicondylitis which is [patient] is that golfer's elbow [doctor] yes same thing have you been golfing a lot [patient] well not in the past year and a half i've had this for a long time [doctor] okay also known as pictures elbow [patient] well i have n't been pitching either [doctor] hmmm well in any case what i'm gon na have to do is i'm gon na send you up for mri to take another look at this [patient] mm-hmm [doctor] that will be our next step so we'll get you scheduled for the mri probably get you in pretty quick here since we're a private practice [patient] thank god [doctor] yeah and once you get the mri i'll know a little bit more what i'd like to do is something called a whole blood transfusion have you heard of that before [patient] no please tell me remind me [doctor] yeah it should help with the healing of your elbow it's just a procedure we'll stick a needle in your elbow [patient] you do a stick needle in my elbow [doctor] mm-hmm and help with some of the healing of your elbow [patient] so it's kinda like dry needling then [doctor] no [patient] not at all [doctor] what is it [patient] is it is that that thing where like you take the blood out of like say my my thigh [doctor] mm-hmm [patient] and then you literally inject it into my tendon [doctor] yes [patient] that it activates the healing [doctor] yeah that's exactly what it is [patient] interesting cool [doctor] yeah [patient] maybe i have heard about that [doctor] we've we've had some really good responses from other patients on it so hopefully i mean that should be a good solution for you since you've been having issues with this [patient] i'm excited [doctor] yeah and we can hopefully get you scheduled for that in the next couple of weeks it's not not a major procedure and you should heal in the next two weeks so that wo n't be a problem especially considering that you're expecting a newborn soon we want to make sure you're all healed for that [patient] wow i did n't even say that [doctor] i read it in your chart [patient] man you doctors are good [doctor] yeah anything else going on today [patient] just trying to figure out how you're doing [doctor] very good thank you [patient] you're welcome [doctor] nice to see you [patient] you have a good day

CHIEF COMPLAINT Bilateral elbow pain, right worse than left. HISTORY OF PRESENT ILLNESS Dylan Bennett is a pleasant 53-year-old male who presents to the clinic today for the evaluation of bilateral elbow pain, right worse than left. The patient has been experiencing bilateral elbow pain, right worse than left, for approximately 1.5 years. His pain is localized to the medial aspect of his elbows and is described as being extremely sore, worse with increased use of his upper extremities. Of note, he utilizes heavy weights for strength training and was very active in sports when he was younger, primarily playing basketball, baseball, and football, but he denies having any pain at that time. Applying ice to the area has not been helpful, but he does use ibuprofen 800 mg 3 times daily. SOCIAL HISTORY The patient reports that utilizes heavy weights for strength training. He was also very active in sports when he was younger, primarily playing basketball, baseball, and football. He is expecting a newborn baby in the near future. MEDICATIONS The patient reports that he has been taking ibuprofen 800 mg 3 times daily. REVIEW OF SYSTEMS Musculoskeletal: Reports bilateral elbow pain, right worse than left. PHYSICAL EXAM CV: Pulses are equal in all extremities. NEURO: Sensation is normal to light touch distally. MSK: Examination of the right elbow: Limited range of motion with extension with pain. Full range of motion with flexion with pain. Pain to palpation along the medial aspect. No pain to palpation on the lateral aspect of the elbow. Pain with supination. No pain with pronation. Examination of the left elbow: minimal pain with flexion and extension Slight Limited ROM on extension of the arm. Pain with supination. No pain with pronation. RESULTS X-ray images of the bilateral elbows were obtained and review in office today. These reveal no evidence of fracture or bony misalignment. ASSESSMENT Bilateral medial epicondylitis. PLAN After reviewing the patient's examination and radiographic findings today, we had a lengthy discussion in regards to his current symptoms. I want to get an MRI of the bilateral elbows for further evaluation. We discussed the possibility of performing a whole blood transfusion to encourage healing, and the patient is already familiar with this procedure.

aci

D2N038

[patient] hey bruce so see here my my notes here is you here he had positive lab work for hep c so how're you doing today [doctor] i'm doing okay but i'm a little bit anxious about having hep c i've really surprised because i've been feeling fine they had done it as you know a screen as just part of my physical so i'm really surprised that that came back positive [patient] okay so in the past have any doctors ever told you that you had hep c [doctor] no never that's why i'm i'm so surprised [patient] okay so just you know i need to ask do you have a history of iv drug use or you know have known any hep c partners [doctor] i mean i used to party a lot and even did use iv drugs but i have been clean for over fifteen years now [patient] okay that that's good i mean i'm i'm happy that you were able to to kick that habit i know a lot of my patients that i see you know they're still dealing with with those dements so i'm i'm i'm happy that you're able to do that so hopefully we can get you better okay [doctor] thank you [patient] so what about alcohol use is that something that you used to do a lot [doctor] i did i did i mean i i still have a beer here and there everyday but not as much as i used to [patient] okay and have you ever smoked before [doctor] i do smoke i smoke about one to two cigarettes per day i've cut down a lot but i'm just having a hard time kicking those less too [patient] yeah yeah and that that's something i've got to work on too because hep c along with smoking you know both of those are n't are n't good so hopefully we can help you out you know if your pcp has n't prescribe something for you already and possibly we can we can do that for you as well [doctor] okay [patient] so do you have any other medical conditions [doctor] no i'm actually other than that i just had my physical and i'm not taking any medications no i'm i'm pretty good otherwise [patient] okay and what conditions would you say run in your family [doctor] i have high blood pressure diabetes and depression [patient] okay [doctor] alright so let me go ahead and do a quick physical exam on you so i reviewed your vitals and everything looks good and on general appearance you appear to be in no distress no jaundice on the skin on your heart exam you have a nice regular rhythm rate [patient] regular rate and rhythm with a grade two out of six systolic ejection murmur is appreciated on your lung exam your lungs are clear without wheezes rales or rhonchi on your abdominal exam bowel sounds are present your abdomen is soft with no hepatosplenomegaly [doctor] hepatosplenomegaly yes let me i will change that one [patient] splenomegaly and on your muscle exam there is no gait disturbance or edema so i did we i was able to review your your results of your recent lab work and your hcv antibody test was positive so your your liver panel we did one of those and it showed an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so that's pretty good so let's talk a little bit about my assessment and plan for you so you do have hepatitis c so your initial labs were consistent with that hep c diagnosis and so you know i do n't know if you read much about hep c but hepatitis c is a viral infection that does affect your liver and you've most likely had it for several years now it it it most patients do n't see symptoms until years later so the next step that i would like to do is just confirm the diagnosis with some additional blood work so that includes checking your hep c rna and your hcv genotype and i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and we will do that by ordering an ultrasound elasto elastography with this information we will we we will be able to know how we can proceed as far as treatment right so how does that sound [doctor] i hmmm so i do have a wife and kids so should i be worried about them [patient] okay yeah so we can start with the same screening that you had for august first so we'll just let's do that hep c antibody test and i'll actually help you set up those appointments with your your family doctor and then we can just see you back in three weeks and based on the results you know we will take action as needed okay [doctor] okay that sounds good [patient] alright [doctor] alright [patient] my nurse will be in with those those orders [doctor] alright thank you [patient] alright thanks [doctor] bye

CHIEF COMPLAINT Hepatitis C. HISTORY OF PRESENT ILLNESS Bruce Ward is a pleasant 60-year-old male who presents to the clinic today following a positive result in a hepatitis C antibody test. He was sent to obtain the hepatitis C antibody test as part of a routine physical. He states he is anxious with the results and denies he has ever been diagnosed with hepatitis C. The patient admits to intravenous drug use in the past; however, he notes it has been longer than 15 years since his last usage. He also reports a history of heavy alcohol use. He continues to drink a beer on occasion. The patient currently smokes 1 to 2 cigarettes per day. He notes he used to smoke more and is having difficulty with complete cessation. MEDICAL HISTORY The patient denies any significant past medical history. SOCIAL HISTORY The patient is married with children. He reports history of IV drug use 15 years ago. He currently drinks beer occasionally. The patient reports smoking 1 to 2 cigarettes per day. FAMILY HISTORY He reports a family history of high blood pressure, diabetes, and depression. MEDICATIONS Patient denies taking any current medications. VITALS All vital signs are within normal limits. PHYSICAL EXAM CONSTITUTIONAL: In no apparent distress. CV: Regular rate and rhythm. Grade 2 out of 6 systolic ejection murmur is appreciated. RESPIRATORY: Lungs are clear without wheezes, rales, or rhonchi. GI/GU: Abdomen is soft with no hepatosplenomegaly. Bowel sounds are present. SKIN: No jaundice. RESULTS The HCV antibody test was reviewed today and is positive. Liver panel revealed an elevated AST at 39 U/L. The ALT, albumin, and total bilirubin were all within normal limits. ASSESSMENT Hepatitis C. PLAN After reviewing the patient's laboratory findings today, I have had a lengthy discussion with him in regard to his current symptoms. His initial labs were consistent with a hepatitis C diagnosis. I have recommended that we confirm the diagnosis with additional blood work including checking his hepatitis C RNA and HCV genotype. I have also recommended that we obtain an ultrasound elastography to evaluate for fibrosis of the liver. The patient is married with children and is concerned about their hepatitis C status. I advised the patient that his family should be screened and we will assist him with setting appointments with their primary care physician. INSTRUCTIONS The patient will follow up with me in 3 weeks to review his results and discuss further treatment.

aci

D2N039

[doctor] hi virginia how are you today what brings you in [patient] i'm doing alright i started seeing this new pcp last year and you know she has been doing a lot of changes to my medication and making sure everything is up to date and she my noticed that my blood pressure has been quite high so she added to medications but and but i you know i've been taking them i've been really good and i i before i was n't but now i am and we're still having a hard time controlling my blood pressure so she thought it would be a good idea for me to see you especially since she noted some on my last blood work she said something about my kidneys [doctor] okay yeah so okay let's before i dive into a lot of that tell me a little bit about how you've been feeling [patient] i would say you know most of the days i feel fine i'm still busy at work i definitely can tell though when my blood pressure is high [doctor] okay you measure it at home you you you measure your blood pressure at home [patient] yeah i she wanted me to get a blood pressure cuff so i did start getting checking my blood pressures probably like a few times a week [doctor] okay [patient] and so then i noticed that it has been getting higher the other day was even as high as one seventy over ninety [doctor] wow [patient] so i did call my pcp and she increased the meds again [doctor] yeah okay now i i just have a couple questions about that are you using a an electronic blood pressure recorder or do you have somebody help you at home [patient] yeah she i have a a electronic one an electronic arm one [doctor] okay okay yeah that's good that's good and have you ever tried do you go to cvs at all [patient] yeah i i do but i've noticed like since the pandemic i do n't see the blood pressures anymore [doctor] okay okay yeah i i thought the one down on main street they i thought they just brought that one back so [patient] did they [doctor] yeah [patient] that's good to know [doctor] you may wan na check that but okay so that's good but i what i'd like you to do with that is i'd like you to keep a record of them for me for my next visit with you so let's talk a little bit about your diet tell me how how is your diet what what are the what kind of foods do you like what do you eat normally [patient] alright do you want the honest answer [doctor] well yeah that would be better [patient] so i really you know with everything going on i really been trying to get better but i mean during football season it's really difficult i really love watching my games so have a lot of pizza wings subs like i said i've been trying to cut down especially on days where there is no games but it probably could be better [doctor] okay i think we all can say that but i do wan na just hey i do n't know that if you've tried it or not but there is a new restaurant down on fifth street and it is nothing but solids and i you know when i heard this i was like okay yeah it's just another these solids are absolutely amazing so if you ever get a chance yeah if you ever get a chance try try that i mean i think you would enjoy them because they're salads that they make are just out unbelievable so let me go ahead and i just have a few more questions and i'm gon na just ask these in in order and you just tell me and then we will come back and talk about them do you have any headaches [patient] really just when my blood pressure gets really high i have some mild headaches but otherwise i do n't have it on a regular basis [doctor] okay what about chest pain [patient] no chest pain [doctor] shortness of breath [patient] no shortness of breath [doctor] even with exertion [patient] even with exertion [doctor] okay do you have any swelling in your lower extremities at all that you noticed [patient] not if i'm on my feet for a long time i'll notice a little bit of swelling but otherwise no [doctor] okay and then a couple other family history questions anybody in the family have kidney disease or significant high blood pressure [patient] both my parents do have high blood pressure and one of them did have kidney disease [doctor] okay okay and in the the the form that you filled out when you came in it says that you are on ten milligrams of norvasc daily and carvedilol twenty five milligrams twice a day is those the medicines you're on [patient] yes i was also on lisinopril before but with the adjustments yeah those are the ones i'm on [doctor] okay and so here's where i think we are going to go do you take any nonsteroidals like advil or motrin or aleve [patient] yeah just once in a while for my like any knee pain or back pain that i have but again not like everyday [doctor] okay and then lastly what kind of alcohol intake do you have you know do you consider how many drinks a week is really what i'm looking for [patient] i'll have a couple of beers during the week and like one or two on the weekends [doctor] okay okay so lem me do a quick physical examination so i looked at your vitals when you came in today and your blood pressure it's still high it's one sixty nine over seventy four your heart rate was eighty eight and your oxygenation was ninety eight percent so those are all fairly good except that blood pressure's a little higher than we'd like to see now when i look at your neck i do n't see any jugular vein distention and i'm gon na listen here real quick no i do n't hear any carotid bruits i'm gon na listen to your lungs okay your lungs are clear and let me listen quickly to your heart i do hear that a two over six systolic ejection murmur and we'll we're gon na have to take a little bit look extra look at that that's when i i can hear an extra sound when i'm listening to your heart and you do have a small amount of one plus pitting edema bilaterally now i did so you do have that your diagnosis is uncontrolled hypertension you know and i think you're aware that that's what your your physician's been treating you for and most of the time this cause is is the cause of this is multifactorial it's not that there is just one thing causing it so we may need to be changing your medicine around and i'm gon na talk to your doctor but first thing before we make any more medication changes i want to order some tests first to rule out if there is any specific cause for this so first order will be a renal artery ultrasound and what i'm looking for there is that there is no areas of areas of narrowing in the the blood vessels of your kidneys that would be the cause of your hypertension in addition to that i'm gon na order a you get another urine collection some morning aldosterone levels reining levels and a twenty four hour urine and these things can really show me if there is any problems with your adrenal glands again this is a lot of big words but you know i'm i i'll write this all out for you i want you to decrease your alcohol i know you like those beers but let's bring it down to maybe one a week or two a week just to get those down lower and then your salt intake you need to be very judicious about decreasing that salt intake i'm gon na give you a referral to a nutritionist to discuss those changes for that you need and and they will help you get that cleared up and then finally stop taking any nonsteroidal medicines such as your advil or motrin the only thing i really want to want you taking is tylenol for any pain right now i am gon na prescribe one medicine and that's cardura four milligrams and i want you to take that once a day and that's good to see if that can help us with your blood pressure and then finally three weeks i'd like you to return i want you to record all of your blood pressures that you take over the next three weeks and bring them into the office but most importantly if you can try to take them at the same time everyday that would be beneficial for me any questions for me [patient] no i i just it's a lot so i i'm hoping this will work and this will get it under control [doctor] yeah i i think you know this will be you know this we're gon na spend some time together so i'm glad to have you as a patient but you know we got ta try to get this under control and i'm gon na i'll be talking to your pcp just to let them know that you know what my plans are and we'll stay real in sync on treating this as we move forward does that sound like a plan [patient] that sounds good thank you [doctor] okay take care i'll talk to you later [patient] okay alright bye

CHIEF COMPLAINT High blood pressure. SOCIAL HISTORY Patient reports drinking a couple of beers during the week and approximately 1 to 2 on the weekend. She is employed. FAMILY HISTORY Patient reports both of her parents have hypertension and one also had kidney disease. MEDICATIONS Patient reports taking Norvasc 10 mg daily and carvedilol 25 mg twice daily. She occasionally takes anti-inflammatories. REVIEW OF SYSTEMS Cardiovascular: Denies chest pain or dyspnea on exertion. Respiratory: Denies shortness of breath. Musculoskeletal: Denies bilateral lower extremity edema. Neurological: Reports headaches. VITALS BP: 169/74. HR: 88 bpm. SpO2: 98%. PHYSICAL EXAM Neck - General Examination: No jugular vein distension. No carotid bruits. Cardiovascular - Auscultation of Heart: Grade 2/6 systolic ejection murmur. Musculoskeletal - Examination: 1+pitting edema in the bilateral lower extremities. ASSESSMENT AND PLAN 1. Hypertension, uncontrolled. - Medical Reasoning: The patient's elevated blood pressure is consistent with uncontrolled hypertension. - Patient Education and Counseling: We discussed the nature of the diagnosis and that this is typically multifactorial. I advised the patient that further testing should reveal additional information. She was encouraged to reduce her intake of alcohol as well as her salt intake. I recommended that she stop taking anti-inflammatories and use Tylenol as needed for pain. We also discussed the importance of home blood pressure monitoring of the next 3 weeks to see if the medication is beneficial. - Medical Treatment: Renal artery ultrasound ordered. Urine collection, morning aldosterone levels, renal levels, and a 24-hour urine were also ordered. Referral to nutritionist provided. Prescription for Cardura 4 mg once a day provided as well. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow-up in 3 weeks and will bring her blood pressure log with her.

aci

D2N040

[doctor] carolyn is a 34 -year-old female with a history of diabetes mellitus type two who is here today with a headache so hi there carolyn it's nice to see you again listen i'm sorry you're having headaches well let's talk about it but i would like to record this conversation with this app that's gon na help me focus on you more would that be okay with you [patient] yes that's okay [doctor] okay great thanks so carolyn tell me about your headache and headache or headaches when did when did they start and and what symptoms are you having [patient] my headache started about a week ago it's feeling like a dull pain in the back of my head i have flushing in my ears they get really red and hot and sometimes i just feel a little bit dizzy when i get these headaches but i've taken tylenol and advil and it's not really going away it just keeps coming back [doctor] okay and alright and so this started about a week ago has it been fairly constant since it started or does it come and go does it come and go or what [patient] it comes and goes i it it's relieved when i take my tylenol or advil but then it comes right back [doctor] hmmm okay and do you notice any any timing difference you know is it is it worse in the morning worse in the evening is there anything else that makes it better or worse [patient] it's definitely worse in the evening [doctor] okay and do you feel any sort of tightness in the back of your neck or in your shoulders or you know you said it's in the back of your head primarily any discomfort anywhere else [patient] yes no just in the back of my head [doctor] okay and did the headache start all of a sudden carolyn or has it been gradual or what [patient] i've been under a lot of stress lately so maybe about when some stress started occurring [doctor] okay okay and alright and have you noticed any fever along with the headache [patient] no no fever [doctor] okay and any visual changes you know wavy lines in your vision spots in your vision or anything like that [patient] no [doctor] okay and have you had headaches like this before [patient] i have [doctor] okay so this is n't the worst headache you've ever had what did you say [patient] no it's not [doctor] okay alright and so okay fair enough now how's your diabetes been been been doing lately have you what have your blood sugars been running in the low one hundreds or two hundreds or what [patient] i have n't been checking my blood sugars [doctor] really okay well we will get you back on that and and we can talk about that but how about your metformin are you still taking the five hundred milligrams once a day no actually it looks like we increased your metformin to five hundred milligrams twice a day last visit are you still taking that [patient] yes [doctor] okay great and okay you're still watching your diet and getting some exercise [patient] i have not been eating well because i've been stressed over the last week but i have n't been exercising for maybe the past week but generally i've been doing better [doctor] okay the headache has has maybe made you feel uncomfortable and prevented your your exercise would you say or what [patient] yes it has [doctor] okay okay so you probably have n't been out golfing i remember you're a big golfer so not not lately uh so you know being [patient] not lately [doctor] being down being down here in florida we got ta get get some golf in so hey did you see the masters by the way a few weeks ago was n't that i do n't know did you happen to catch it [patient] i did [doctor] yeah that was crazy what a what a finish what an amazing what an amazing tournament right what do you think yeah yeah that's great well we'll we'll get you feeling better and get you back out there and now are you still working a lot on the computer ac or [patient] i am [doctor] carolyn okay yeah you're still working a lot on the computer for work okay are you taking breaks every hour or so you know get up stand around walk stand walk around that can be helpful [patient] no i really do n't get the opportunity to [doctor] hmmm okay understood alright well listen let's go ahead and examine you okay so so on your physical exam your physical exam is pretty normal unremarkable for the most part and you know few things a few exceptions so first of all on your heent exam your eye exam your extraocular motions are intact without pain you have a funduscopic exam that shows no papilledema that's good that just means there's no swelling in the back of your eye and on your neck exam you do have some posterior mild posterior paraspinal muscular tenderness in the cervical spine and in bilateral trapezius musculature as well and some tightness in those muscles as well and otherwise on your exam let's see your heart exam on your heart exam you have that grade three out of six systolic ejection murmur that's unchanged from your prior exam so it just means i hear some sounds in your heart as it's beating and i'm not too worried about that we'll watch that and otherwise normal heart exam and and your physical examination otherwise is normal and unremarkable and so now let's talk about my assessment and your plan so carolyn for your first problem of the headache i do think that you have a tension type headache and i think this because you've got some tension and tightness in your paraspinal muscles meaning the muscles around your neck and your shoulders and you know working at the computer i think is contributing to this and also probably the stress so you can continue to take that tylenol for the pain i'm also gon na give you a mild muscle relaxant i'll write you for flexeril five milligrams three times a day and you can take that that will help relax those muscles in your neck and that should help with the symptoms i want you to come back or give us a call if the headaches become more severe or suddenly worsen or you develop a fever but i do n't think that this is a a sign of a stroke or any bleeding in your brain or anything like that i think it's more related to tightness in your muscles in your neck now for your second problem of your diabetes mellitus let's continue you on the metformin five hundred milligrams i am going to order a hemoglobin a1c and also a cbc and a chem-12 to check some of your blood tests blood chemistries and so forth and we will continue you on the metformin i do want you to check your blood sugars daily and that will be very helpful so when you come back in a month i want you to bring those numbers with you we can talk about it again and please do try to get back into your exercise routine that's really gon na help you keep those blood sugars under control as well okay so how does that sound for a plan any other questions for me [patient] well would it so only call if if it gets worse or not any better [doctor] yeah that that just right but also let's set up an appointment in four weeks and i wan na see you back in four weeks if it's not if the headache is not better within the next few days with this flexeril then you can give us a call and and get back in later this week or early next but definitely if things get worse give us a call sooner and you know i meant to ask you on i wanted to ask if you had a history of any any trauma meaning have you hit your head or you have n't fallen hit your head or anything like that have you [patient] no no i think it's just stress [doctor] okay alright understood okay great well then i'll see you back in a month if not before okay you take care of yourself nice seeing you [patient] thank you [doctor] sure

CHIEF COMPLAINT Headache. MEDICAL HISTORY Patient reports history of diabetes mellitus type 2. SOCIAL HISTORY Patient reports she enjoys golfing. MEDICATIONS Patient reports taking metformin 500 mg twice a day. REVIEW OF SYSTEMS Constitutional: Denies fever. Eyes: Denies vision changes. HENT: Reports ear flushing. Neurological: Reports headaches and dizziness. PHYSICAL EXAM Eyes - Examination: No papilledema. - Extraocular Muscles: Grossly Intact without pain. Neck - General Examination: Mild posterior paraspinal muscular tenderness in the cervical spine and bilateral trapezius musculature as well tightness. Cardiovascular - Auscultation of Heart: Grade 3 out of 6 systolic ejection murmur that is unchanged from prior exam. ASSESSMENT AND PLAN 1. Headache. - Medical Reasoning: Patient presents with symptoms similar to a tension headache. On exam she has tension and tightness in her paraspinal muscles as well likely due to working at the computer. Additionally, I think her stress level is also a contributing factor. - Patient Education and Counseling: I discussed the diagnosis with the patient today. I explained that her headaches may be caused by tension around the muscles around her neck and shoulders. I advised her that her symptoms do not appear related to signs of a stroke or brain bleeding. Questions were asked and answered today. - Medical Treatment: She can continue to take Tylenol for the pain. Prescription for Flexeril 5 mg 3 times a day is provided as well. 2. Diabetes mellitus. - Medical Reasoning: Due to her headaches, she has been inconsistent with her exercise and checking her blood sugar. - Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. We also discussed the importance of keeping a watchful eye on her blood sugar levels. - Medical Treatment: She will continue taking metformin 500 mg daily. Order for hemoglobin A1c, CBC, and CMP provided today. She will check her blood sugar daily and will bring that information in on her next visit. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 1 month. She can follow up or call sooner if her headaches become more severe or suddenly worsen or she develops a fever.

aci

D2N041

[doctor] hi teresa what's going on i heard that i heard that you're having a sore throat you're not feeling well [patient] yeah my throat has been hurting me for like four four days now and i think i had a fever last night because i was really sweaty but i did n't take my temperature because i was already in bed [doctor] okay alright so four days ago you started feeling badly okay now were you having chills [patient] yeah last night i was chills and i had lot of sweating and it's really hard to swallow [doctor] it's really hard to swallow okay now do you have pain every time you swallow or is it just periodically [patient] every time i swallow i'm even having trouble eating i can drink okay the like really cold water feels good [doctor] okay that's what i was gon na ask you okay so you're able to drink water and are you able to drink any other fluids have you been able to drink any you know i do n't know juices or milk shakes or anything like that [patient] well besides my wine at night i really just drink water all day [doctor] okay well i like to drink wine too what's your favorite type of wine [patient] peanut grooves yes [doctor] it's a good one i like that too i am also a pino navar fan so there you go alright well let's now do you feel sick to your stomach at all [patient] no i have a little bit of a stuffy nose not too bad it's really just my throat but i think my tonsils are swollen too [doctor] and your tonsils are swollen too now has anyone else sick in your household [patient] i do have little kids that go to school so they've always got you know those little runny noses or cough but nobody is really complaining of anything [doctor] okay alright now have you had strep throat in the past [patient] when i was a kid i had strep throat but i have n't had anything like that as an adult [doctor] okay alright and what do you do for work [patient] i i work as a cashier in a supermarket [doctor] okay alright and did you get your covid vaccine [patient] yep i did get my covid vaccine but it really made me feel sick so i'm hoping i do n't have to get another one later this year [doctor] okay did so you just got the two vaccines you did n't get the booster [patient] no i did n't get the booster because i really have n't had time to feel that sick again it really knocked me down for like two days and with the little kids it's really hard [doctor] okay alright well i saw that they did a rapid covid test when you came in here and that was negative so that's good so you do n't have covid which is which is good now let's talk a little bit about your hypertension and hypertension since i have you here did you ever buy that blood pressure cuff that i asked you to buy [patient] yes i did i blood the blood pressure cuff and my blood pressure is like all over the place sometimes it could be like one twenty for the top number sometimes it could be one forty for the top number i i do n't really remember the bottom number though [doctor] okay that's okay are you taking the lisinopril i think we have you on twenty milligrams a day [patient] yep i take it every morning with my multivitamin and my vitamin d [doctor] okay alright and are you watching your salt intake [patient] i really like my chips with my wine [doctor] is n't that the best we we could get along really well outside of here alright and then tell me a little bit about your diabetes now are you are you watching your blood sugars are you taking them at home [patient] sometimes i take that all that often again that could be all over the place sometimes i get if i take it first thing in the morning it'll be like eighty or ninety but at night sometimes it could be one forty [doctor] okay alright and i are you still taking the metformin we have you on a thousand milligrams twice a day [patient] uh uh yes i do take it i take it with my breakfast and with my dinner [doctor] okay alright great alright now are you are you a meds fan or a yankie's fan or god for a bit of filly's fan [patient] nope [doctor] no [patient] no do n't do n't like sports [doctor] do n't like sports just the wine [patient] no [doctor] okay alright well let's go ahead i wan na just do a quick physical exam now i'm gon na be calling out some of my findings and i'm gon na let you know what that means when i'm done okay so looking here first at your vital signs your vital signs look pretty good you do have a low-grade fever of about a hundred . four right now but otherwise your blood pressure is pretty good it's about one thirty two over eighty and your heart rate is eighty four now that looks pretty good so i'm just gon na go ahead and examine you so on your facial exam i'm gon na just press on your face here does this hurt [patient] no not no it does n't bother me [doctor] okay on facial examination the patient has no pain to palpation of the frontal or maxillary sinuses on nasal examination there is edema and erythema of the nasal turbinates bilaterally with associated clear discharge open up your mouth and say [patient] ah [doctor] on throat examination there is bilateral erythema and edema of the peritonsillar space with exudates present bilaterally the uvula is midline on your neck exam i do appreciate some cervical lymphadenopathy on the right hand side on your lung exam your lungs you have some coarse rhonchi at the bases that clear with cough and on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur or or rub so what does all of that mean teresa so all of that means is that yes you're showing signs of what we call an upper respiratory infection and i'm concerned that you might have some strep in the back of your throat based on the findings so let's just talk a little bit about my assessment and plan for you okay so for your first problem of your sore throat i'm gon na go ahead and have the medical assistant come in and swab you for a rapid strep test and if that's positive i wan na go ahead and place you on or prescribe amoxicillin five hundred milligrams three times a day for ten days and i'm gon na give you some lidocaine swish and swallow so that will help with some of the pain and you can take some ibuprofen as needed which will also help with the pain and some of that fever okay i do want you to go ahead and continue to to hydrate as much as possible what kind of questions do you have about that [patient] no that sounds good i just wanted to be sure i was okay because of the little kids [doctor] sure now for your next problem of your hypertension i wan na go ahead and order a lipid panel on you and i think i do wan na increase i do wan na increase the lisinopril to forty milligrams once a day just to get your blood pressure under better control and we'll see how you do on the forty milligrams once a day for your third problem of your diabetes let's go ahead and order a hemoglobin a1c and just to make sure that we do n't have to make any adjustments to your metformin how does that sound [patient] sounds good [doctor] any questions [patient] nope that's everything [doctor] okay bye good to see you i'll be in touch

CHIEF COMPLAINT Sore throat. MEDICAL HISTORY Patient reports history of hypertension and diabetes. SOCIAL HISTORY Patient reports working as a cashier in a supermarket. She enjoys drinking wine. MEDICATIONS Patient reports taking lisinopril 20 mg daily, multi-vitamin, vitamin D, and metformin 1000 mg twice daily. REVIEW OF SYSTEMS Constitutional: Reports fever, chills, and profuse sweating. HENT: Reports sore throat, dysphagia, tonsil swelling, and congestion. Gastrointestinal: Denies abdominal symptoms. VITALS Temperature: 100.4 degrees F. Blood pressure: 132/80 mm Hg. Heart rate: 84 BPM. PHYSICAL EXAM Head and Face - Examination: No pain to palpation of the frontal or maxillary sinuses. Ears, Nose, Mouth, and Throat - Examination of Nose: Edema and erythema of the nasal turbinates noted bilaterally with associated clear discharge. - Examination of Throat: Erythema and edema of the peritonsillar space with exudates present bilaterally. The uvula is midline. Neck - General Examination: No thyromegaly, but there is some cervical lymphadenopathy on the right side. Respiratory - Auscultation of Lungs: Coarse rhonchi at the bases that clear with cough. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs. RESULTS Rapid COVID-19 test performed today in office is negative. ASSESSMENT AND PLAN 1. Sore throat. - Medical Reasoning: The patient has experienced sore throat, fever, chills, profuse sweating, and difficulty swallowing for 4 days. There is erythema and edema of the peritonsillar space with exudates present bilaterally as well as edema and erythema of her turbinates, bilaterally. - Patient Education and Counseling: We discussed treatment options today. I have stressed the importance of hydration. - Medical Treatment: We will perform a rapid strep test today. If she is positive for strep, I will prescribe amoxicillin 500 mg 3 times a day for 10 days. Prescription for lidocaine swish and swallow provided for pain relief. ibuprofen can also be taken for pain and fever relief. 2. Hypertension. - Medical Reasoning: The patient states her blood pressure fluctuates often. Her blood pressure today in office was 132/80 mm Hg. - Patient Education and Counseling: We discussed treatment options including increasing her lisinopril and diet modifications. - Medical Treatment: Lipid panel ordered. Prescription for lisinopril 40 mg once a day is also provided. 3. Diabetes. - Medical Reasoning: The patient’s blood sugar fluctuates between 80 to 90 in the morning to 140 in the evening. She is already at 1000 mg of metformin twice a day, which she does take with meals. - Patient Education and Counseling: We discussed the importance of achieving a healthy lifestyle and what effects that can have on her diabetes. - Medical Treatment: I have placed an order a hemoglobin A1c. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

aci

D2N042

[doctor] good morning carolyn how are you [patient] i'm doing alright other than this ankle pain i've been having [doctor] so i see here that you hurt your right ankle can you tell me what happened [patient] yeah so yesterday i was going to take out the trash and it was quite icy i thought i was doing okay job and i just slipped and and fell and i'm pretty sure i heard a pop [doctor] okay and you said this happened yesterday correct [patient] yeah [doctor] okay and have you been able to walk on it at all [patient] no i was so initially when i first fell i was unable to walk at on it at all i had a friend that was visiting and so she heard me fall so she helped me inside now today i have been able to put a little bit more weight on it but i'm still limping [doctor] okay and then what have you been doing for your foot or ankle pain since that happened [patient] so i like iced it last night and kept it elevated and i also took some ibuprofen last night and this morning before coming in today [doctor] okay and can you rate your pain for me [patient] i would say right now it's like a four out of ten [doctor] okay and does the ibuprofen help with that pain [patient] it does it does help with the pain [doctor] okay and when you take your ibuprofen what can you what's your pain level then [patient] so this so what did i just say four [doctor] yes ma'am [patient] four out of ten so four out of ten is with ibuprofen [doctor] it's with ibuprofen okay what's your pain level without then [patient] i would say probably a six [doctor] okay [patient] i'm sorry it's a six out of ten without ibuprofen and it goes down to like a one with ibuprofen [doctor] okay alright that that sounds good have you ever injured that foot and ankle before [patient] you know i've had a lot of injuries to my ankle but i've never hurt this ankle before i just realized an error [doctor] okay you know and i see here that you have a history of playing sports looks like you played soccer in college and then played a little bit of a inner marrow soccer now [patient] yeah [doctor] i'm i'm guessing you probably have n't been able to do that since you hurt your ankle [patient] no i have not been [doctor] so did you hear about the new major league soccer stadium and team that's coming to town they opened in the this year actually they built the stadium have you been down there yet [patient] no i have to get there [doctor] yeah we are all excited it's going to be a good time well have you experienced any numbness or tingling in that right foot [patient] no [doctor] okay so if it's okay with you i would like to do a quick physical exam your vitals look good and everything there looks okay now i'm gon na do a focused exam on your right ankle i do appreciate some ecchymosis or bruising over the lateral malleolus malleolus associated with some edema or swelling of that area you are positive for tenderness to palpation of the anterior lateral soft tissue and now i do n't appreciate any laxity on anterior drawer and inversion stress there is no bony tenderness on palpation to that foot or ankle area now on neurovascular exam of your right foot you have brisk capillary refill of less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch and all of that is consistent with what's present on your left side as well so i did review the results of your of your x-ray the x-ray of your right ankle showed no fracture which is a good thing so now let me talk to you a little bit about my assessment and plan so for the first problem of right ankle pain your symptoms are consistent with a right ankle sprain or i'm sorry right ankle sprain of your lateral ligament complex more specifically your anterior talofibular ligament now this ligament's on the outside of your ankle ankle which got stretched when you fell the best treatment at this time for your sprain is to keep your leg elevated when you're seated and let's continue to ice okay you're gon na be given an air cast which is gon na help stabilize that ankle and i'm also going to prescribe some crutches because i want you to stay off that leg and start walking on it stay off your leg for now and then in a couple of days start walking on it as tolerated do you have any questions or concerns for me [patient] so how long do you think it'll take to heal [doctor] so your symptoms should significantly improve over a few weeks but i'd like to follow up with you and see how you're doing let's say i'll see you again in fourteen days now i do want you to go ahead and continue to take nsaids or ibuprofen as needed to help with any pain and that's also gon na help reduce that inflammation and swelling okay [patient] okay [doctor] alright i will see you again in two weeks carolyn [patient] great thank you [doctor] you're welcome

CHIEF COMPLAINT Right ankle pain. HISTORY OF PRESENT ILLNESS Carolyn Jones is a pleasant 38-year-old female who presents to the clinic today for evaluation of right ankle pain. The patient sustained an injury to her right ankle when she slipped and fell on ice while taking her garbage out yesterday. This was her first right ankle injury. She believes she heard a pop at the time, but denies any associated numbness or tingling. Initially, she was unable to bear weight on the ankle and required help getting inside; however, she is now able to slightly bear weight but ambulates with an antalgic gait. Ice, elevation, and ibuprofen have been helpful at reducing her pain. She rates her current pain as 4/10, her pain without medication as 6/10, and her pain with medication as 1/10. Of note, the patient participates in an intramural soccer league but has not been able to play since this injury. MEDICAL HISTORY The patient reports that she has had several ankle injuries in the past. This is her first right ankle injury. SOCIAL HISTORY The patient reports that she has a history of playing sports. She played soccer in college and is now in an intramural soccer league. MEDICATIONS The patient reports that she has been taking ibuprofen. REVIEW OF SYSTEMS Musculoskeletal: Reports right ankle pain. Neurological: Denies right ankle numbness or tingling. VITALS Normal PHYSICAL EXAM GAIT: antalgic gait CV: Brisk capillary refill to less than 3 seconds. Strong dorsalis pedis pulse. NEURO: Sensation in the right ankle is intact to light touch distally. MSK: Examination of the right ankle: Ecchymosis over the lateral malleolus associated with trace edema in that area. Tenderness to palpation over the anterolateral soft tissue. No laxity on anterior drawer testing or inversion stress testing. No bony tenderness on palpation of the foot or ankle area. Findings are consistent bilaterally. RESULTS X-ray images of the right ankle were obtained and reviewed today. These reveal no evidence of fracture. ASSESSMENT Lateral ligament complex sprain, Right ankle. PLAN After reviewing the patient's examination and radiographic findings today, her symptoms are consistent with a right ankle sprain of the lateral ligament complex, more specifically the anterior talofibular ligament. We had a lengthy discussion regarding the nature of this injury and the course of treatment. I advised her to keep her leg elevated when she is seated and continue to ice her ankle. She should also continue taking ibuprofen as-needed for pain and inflammation management. She will be placed in an Aircast to help stabilize her ankle, and I am going to order crutches so she can remain non-weight-bearing for the next couple of days. At that point, she can start bearing weight on the ankle as tolerated. INSTRUCTIONS The patient will follow up in 2 weeks.

aci

D2N043

[doctor] how are you doing [patient] i'm doing i'm good i'm i'm doing really good i'm here i'm just ready to quit smoking and but i've been having quite a hard time with it [doctor] well i'm glad that you're taking the first steps to quit smoking would you tell me a little bit more about your history of smoking [patient] yeah so i've been smoking for some time now i started in high school and was just you know just experimenting and smoking here and there with friends or at parties and then it just started getting more regular and regular and i do n't even know how i'm 44 now and i'm smoking everyday so yes now i'm up to a pack and a half a day [doctor] okay do you use any other type of tobacco products [patient] no smoking is enough [doctor] okay and i understand that so when you wake up in the morning how soon after waking up do you smoke your first cigarette [patient] i would say probably within an hour of waking up i'll have my first cigarette [doctor] okay so i'm really excited that you wan na quit and i know that you probably heard this multiple times before but this really is one of the best things that you can do to help your health especially since you have the history of gout and type two diabetes this is really gon na be a great step in you having better long term health outcomes [patient] yeah i know and you know i'm really motivated now because i am about to be a father any day now and i just really wan na be there for my daughter growing up [doctor] hey that's great and that's great to hear congratulations i'm so excited to hear about the new baby [patient] yeah [doctor] i i have a daughter myself have have you picked out any names [patient] we're you know we're deciding between a few names but we're kinda just waiting to see her to see which name fits [doctor] okay alright that sounds good well congratulations again i'm very excited for you and your and and your wife that that's this is great [patient] thank you [doctor] so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried [patient] yeah actually i just went cold turkey one day i woke up and i said you know i've had enough and i know that smoking is not good for me so i woke up and stopped and i actually did really well and i was able to quit smoking for almost a year and then things just started getting really stressful at work they started laying people off and i'm happy i still have a job but that also meant that i was responsible for more things so things just got stressful and i and just started picking it up again [doctor] well you are absolutely correct you know stress can often be a trigger for things like smoking and drinking have you thought what you would do this time when you encountered the stressful situations [patient] yeah i i did n't think about that a lot actually and one thing is i have started learning and trying to do more meditation and then i also just recently joined the gym so i'm really looking forward to working out again [doctor] okay well that's great to hear that you're getting back in the gym that will be good for your long term health too you know helping to maintain that type two diabetes you know those are really great strategies talking about gym for stress relief and and you know we have other products as well that you can use for an additional aid to help you stop smoking have you given any thought to using some type of smoking cessation aid at this time or or what do you think about that [patient] you know i've had you know because i've been trying to do cold turkey and it's not working and some of my friends actually have mentioned using a patch and they they've had some success with that so i think i would i would probably wan na start with that [doctor] okay alright that that sounds good it's good that you've you've picked out one of those aids and have you thought of a quit date i mean we we really wan na talk about when you're gon na say this is the day [patient] yeah you know next monday is actually my birthday so i think that's a good day [doctor] that's a fantastic day and happy birthday coming up on monday [patient] thank you [doctor] so let's talk a little bit about your exam here okay i'm gon na go ahead and do a quick physical exam and i reviewed your vitals and everything looks good including your oxygen saturation blood pressure for today was one twenty eight over eighty eight heart rate was sixty eight respirations were sixteen and your pulse ox was ninety eight percent on room air so those were all really good now on your heart exam you do have a nice regular and your your rate is of regular rate and rhythm or i'm sorry your heart exam for your heart exam notice that your heart is regular in rate and rhythm i do however still appreciate that two over six systolic murmur that we talked about in the past now that's okay we'll just continue to monitor that now for your lung exam i'm gon na go ahead and listen to your lungs your lungs are clear and equal bilateral with no expiratory wheezes and no rales or rhonchi are appreciated on your neck exam i do n't appreciate any lymphadenopathy when i listen i do n't hear any extra noises so i do n't hear any hearing any carotid bruit which is a good thing now for my impression and plan let's talk a little bit about my assessment and plan for you so for your first problem of nicotine dependence first of all i just want to apply you on making this first step to stop smoking and i want you to know with absolute one hundred percent certainty that i'm gon na be with you every step of the way i think it's fantastic that you're very welcome i i i think it's fantastic you've chosen next monday as a quit date and on that day i'm gon na start you with a twenty one milligram nicotine patch and the goal will be to decrease that over time okay now we will work together to decrease that so there is no necessarily hard dates in mind okay be sure to change the patch location each day and that's going to help reduce or avoid that skin irritation that can occur if you use the same location over and over again i would like to see you again in two weeks just to see how things are going and we will reevaluate at that time the dosage for your nicotine patch now we also see further need to discuss any handouts you received today for those common smoking triggers i really want you to keep an eye on and monitor your stress level not only about work but also the fact that you are experiencing are going to be be a new father and we really want to watch any stress you will be experiencing around the birth of your new child so please keep an eye on that and let me know how that goes now for now until we meet in two weeks go ahead and keep up your exercise routine i think that's a great plan and just try to monitor your stress and and maybe think about some things like meditation or adding in some yoga and that type of thing to help further work with your your stress levels so do you have any questions for me [patient] no not at this time [doctor] okay so for your other conditions that we talked about briefly your second condition of type two diabetes we'll let's go ahead and continue to maintain that with diet and exercise and we'll just monitor your type two diabetes i am gon na go ahead and order a hemoglobin a1c for your next blood draw since i'll see you in two weeks go ahead and have that done and we will talk about that when you come back in now for your third problem of your history of gout let's go ahead and continue you on your allopurinol and just you know continue to watch those foods that will exacerbate your uric acid levels any other questions about those [patient] no i think that's it thanks so much [doctor] alright sounds good i'll see you in two weeks congratulations on the baby and and we're excited about next monday that's your quit date [patient] alrighty thank you [doctor] you're welcome i'll see you in two weeks thanks bye-bye [patient] alright bye

CHIEF COMPLAINT Smoking cessation. MEDICAL HISTORY Patient reports a history of type 2 diabetes, gout, and a 2/6 Systolic ejection murmur. SOCIAL HISTORY Patient reports he is a smoker. MEDICATIONS Patient reports taking allopurinol. VITALS Oxygen Saturation: 98% on room air. Blood Pressure: 128/88 mmHg. Heart Rate: 68 beats per minute. Respiratory Rate: 16 breaths per minute. PHYSICAL EXAM Neck - General Examination: Neck is supple without lymphadenopathy. No carotid bruits. Respiratory - Auscultation of Lungs: Clear bilaterally. No expiratory wheezes, rales, or rhonchi. Cardiovascular - Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur. Hematology/Lymphatic/Immunology - Palpation: No enlarged lymph nodes. ASSESSMENT AND PLAN 1. Nicotine dependence. - Medical Reasoning: The patient has a long history of smoking cigarettes. He is currently smoking 1.5 packs per day. He is highly motivated to cease smoking as he is preparing to become a father. - Patient Education and Counseling: I applaud the patient on making this first step to stop smoking. I reassured him that with absolute 100% certainty that I will be with him every step of the way. I explained to the patient that stress can often be a trigger for smoking. He received handouts today for common smoking triggers. I advised him to be watchful and monitor his stress level, not only regarding work, but also his impending fatherhood. The patient and I discussed coping mechanisms for when he encounters stressful situations. I encouraged him to maintain his gym routine, engage in meditation, and try adding in yoga to help further reduce his stress levels. We discussed additional cessation aids. - Medical Treatment: The patient has chosen his birthday, as a quit date. On that day, I am going to start him with a 21 mg nicotine patch, and the goal will be to decrease that over time. We will work together to decrease the dosage of the nicotine patch, so there are not necessarily any hard dates in mind. I recommend he change the patch location each day as that will help reduce or avoid any skin irritation that can occur if he re-uses the same location repeatedly. 2. Type 2 diabetes. - Medical Reasoning: Stable. - Patient Education and Counseling: We discussed that continuing to follow a healthy diet and perform regular exercise will help to maintain his blood glucose levels. - Medical Treatment: We will continue to monitor his type 2 diabetes. Hemoglobin A1c is ordered to be completed by his next visit in 2 weeks. 3. History of gout. - Medical Reasoning: Stable with medication. - Patient Education and Counseling: I advised him to continue to watch for foods that will exacerbate his uric acid levels. - Medical Treatment: He will continue his allopurinol. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS I would like to see him again in 2 weeks to discuss how things are going and to reevaluate the nicotine patch dosage.

aci

D2N044

[doctor] good morning julie how are you doing this morning [patient] i've been better my primary care doctor wanted me to see you because of this this knee pain that i've been having for about six months now [doctor] okay and do you remember what caused the pain initially [patient] honestly i do n't i ca n't think of anytime if i fell or like i i've really been trying to think and i ca n't really think of any specific event [doctor] okay now it it says here that it's in both knees is that correct [patient] yes both my knees [doctor] okay it kinda try let's let's try describing the pain for me please [patient] yeah it's kind of feels like it's like right behind my kneecaps [doctor] okay [patient] and it's like a deep achy pain [doctor] a deep achy pain okay what kind of activities makes the pain feel worse [patient] let's see so anytime so if i'm sitting at my desk and i get up i have a lot of pain so anytime from like standing up from sitting for a while or even going up and down the stairs [doctor] okay so you work from home [patient] i do [doctor] okay okay so there is a lot of desk setting at home is your office upstairs or is it i mean do you have to go up or downstairs to get to it [patient] no well first thing in the morning but otherwise it's downstairs [doctor] okay okay how do you like working from home [patient] you know it has it's plus and minuses [doctor] okay [patient] i like it though my i like my commute [doctor] yeah [patient] i love it [doctor] and the parking i'm sure the parking is [patient] and the parking is great [doctor] yeah i you know if i could do telehealth visits all day long i would be totally happy with that yeah and just set it home and do those so you mentioned is there anything that makes that pain feel better [patient] usually after like if i feel that pain and then i just it does get better [doctor] okay now you mentioned earlier that you tried some things in the past what have what are they and did they work at all [patient] yeah i've done some ibuprofen or aleve sometimes some tylenol and that does help [doctor] okay [patient] it takes the edge off [doctor] okay but you're never really pain free is that what i hear you saying [patient] not really unless i'm like really just resting which i hate to do but otherwise any type of movement especially from sitting it causes pain [doctor] okay so are you active other than going up and down the steps to your office [patient] very i'm a big runner i love to run i run about five to six miles a day but with this knee with with these knee pain that i've been having it's i barely can even do half a mile [doctor] yeah you know what that's that's i am a biker and i know that once you get that into your you know you have loved doing that activity it's so frustrating when you ca n't it's almost like a it's almost like a dry it almost becomes a drug when you get up [patient] exactly [doctor] yeah [patient] it's [doctor] okay so have you noticed any redness or swelling in your knees [patient] no [doctor] okay and have you ever injured your knees before [patient] you know despite how active i am i you know i've never [doctor] okay [patient] injured or broken a bone [doctor] okay great so let's go ahead and do a i just wan na take a look here i reviewed your vitals and overall they look good your blood pressure is one twenty over seventy your your heart rate is sixty and your respiratory rate is fourteen those are all phenomenal numbers as i listened to your heart it is at a regular and a slower rate but i do n't hear any extra sounds so there is no murmurs as we go through that now on musculoskeletal exam you have a normal gait i watched you you know kinda walk in here this morning your strength i just wan na check it when i go ahead and i want you to move your leg okay your muscle strength is is good you do have a three out of five for abduction of your legs bilaterally and that's you know kinda bringing your legs in the remainder of your muscle strength for your lower extremities is a five out of five now let me focus specifically on your knee examination i do n't see any redness or ecchymosis or warmth of the skin and those are big words you know i do n't see any bruising or or that redness there is no effusion that's just like a fluid underneath the knee i do n't appreciate that any at all you do seem to have some tenderness when i palpate and you do have a positive patellar grind test when you stood up i could feel that as we went through there you did say you had that knee pain with squatting but your lachman your anterior and posterior drawer and mcmurray test are all negative bilaterally neurologically and your your your lower extremities your patella and your achilles reflex are symmetrical and that's good so i did review the x-rays of both your knees which shows no fractures or osteoarthritis so based on what you told me and reviewing the mri that you had done before you came in your symptoms are consistent with patellofemoral pain syndrome and this is a really common condition that we see that causes knee knee pain especially in really active young people that's probably why i do n't get it when i'm riding my bike forever and ever now this condition has to do with the way your kneecap moves across along the groove of your thigh bone your femur so for pain i want you to continue to take the ibuprofen or any other anti-inflammatories you know aleve or any of those as you need it to help with the pain now i am going to recommend physical therapy well they will show you a number of lower extremity exercises this is probably one of the best things that you can do and this will help increase your lower extremity strength your mobility and correct any incorrect running mechanics that you might have do you have any questions for me [patient] so will i be able to run again [doctor] absolutely my goal is to get you out there and maybe we can cross pads on the the bike trail some day you are gon na have to take it a little bit easy for now but we are gon na get you back and once we do that i think you will be really pleased is there anything else [patient] no i think that's it [doctor] okay have a great day [patient] okay you too [doctor] thank you [patient] bye

CHIEF COMPLAINT Bilateral knee pain. SOCIAL HISTORY The patient is an avid runner. She also works from home. REVIEW OF SYSTEMS Musculoskeletal: Reports bilateral knee pain. Denies knee swelling. Skin: Denies redness. VITALS Blood pressure: 120/70 mmHg Heart rate: 60 bpm Respirations: 14 PHYSICAL EXAM Neurological - Orientation: Normal gait. Patellar and Achilles reflexes are symmetrical. Cardiovascular - Auscultation of Heart: Regular, slower rate. No murmurs. Gastrointestinal - Examination of Abdomen: No masses or tenderness. - Auscultation: Bowel sounds normal in all 4 quadrants. Musculoskeletal - Examination: No clubbing, cyanosis, or edema. Normal gait. 3/5 abduction strength of the bilateral lower extremities. Otherwise, 5/5 strength in the bilateral lower extremities. - Bilateral knees: No erythema, ecchymosis, or warmth. No effusion. Tender to palpation. Positive patellar grind test. Lachman, anterior and posterior drawer, and McMurray test are all negative bilaterally. RESULTS X-ray of the bilateral knees are reviewed and reveal no fractures or osteoarthritis. ASSESSMENT AND PLAN 1. Patellofemoral pain syndrome, bilateral. - Medical Reasoning: After reviewing her x-ray, previous MRI, and exam findings, her symptoms are consistent with patellofemoral pain syndrome. - Patient Education and Counseling: We discussed the nature of this condition in detail. I encouraged the patient to be conservative with her physical activity for now. - Medical Treatment: Continue with over-the-counter NSAIDs for pain relief We are going to refer her to physical therapy to help strengthen her lower extremities, increase mobility, and demonstrate proper running mechanics. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

aci

D2N045

[doctor] hi abigail how are you today [patient] hello hi nice to meet you i'm i'm doing okay [doctor] good i'm doctor sanchez and i'm gon na go ahead and take a look i saw with your notes that you've been having some knee pain yes that's that's true you know it's been going on for a while i like to run i do jogs i sign up for the 5k tack you know sometimes the marathon and i have n't been doing longer distances because [patient] when i'm running i my right knee here it just starts to ache and it's it's just to the point where i need your opinion [doctor] okay okay what have you done for it so far what makes it better what makes it worse [patient] well it used to be that when i run it ache and then i put ice on it and then it would be okay so i do ice and ibuprofen [doctor] okay okay and did you see anybody for this before coming into the office here [patient] yeah i doctor wood is my primary care provider and i talked to him about it actually over the years and this last visit he said he referred me to you [doctor] okay okay good so ice and rest makes it feel better running and and activity makes it hurt a little bit more is that correct [patient] yeah that's right [doctor] okay do you have any family history of arthritis or any of those type of immune diseases [patient] i'm trying to think no i do n't think so no [doctor] okay and do you get is it is this primarily worse in the morning or does it is it just there all the time when it comes on [patient] it actually is worse towards the end of the day [doctor] okay [patient] once i'm on my feet all day it starts to ache towards the afternoon [doctor] okay so let's go ahead and i want to do a quick examination here your blood pressure and was one twenty over sixty that's phenomenal your heart rate was fifty eight and you can tell that you're a runner with that that level of a heart rate and your respirations were fourteen so all of that looked very good there was no fever when you came in when i'm gon na just quickly listen to your heart and lungs okay those those sound good but let me get let's focus here on your lower extremities i'm i'm gon na look at your your left knee first when i move your left knee do you get any type of pain or is it just feel like normal and it's always your pain's always isolated to the right [patient] that feels that feels normal [doctor] okay okay so let me i just want you to back up here in the stretcher a little bit more and i'm just gon na do some movement of your knee any okay so i want you to push your leg out against my hand does that hurt [patient] no [doctor] okay and if you pull back does that hurt a little bit [patient] no [doctor] okay and i'm gon na move it around so when i look at the knee there is no redness there's no swelling i can appreciate a a small amount of effusion and that means that there's a little bit of fluid under the knee or in that knee's joint space and there is there is several reasons that could be now when i push on your knee does it hurt more on the inside or does it hurt more on the outside here [patient] the the right knee here hurts on the outside [doctor] okay okay and you've got a good pedal pulse so you know you can feel that and when i touch your feet you do n't have any numbness or tingling or anything like that [patient] no uh uh [doctor] okay well so what i want to tell you is that i think you have a knee sprain from overuse and we see that sometimes in runners now unfortunately you're gon na have to take some a little bit of time off of of active running but i do n't think it will be that long until we can get you up and running again now i reviewed the x-rays that we did when you first came into the office here this morning and the joint spaces of that right knee are are well maintained i do n't see any evidence of any fracture and when compared to the left knee everything looks good so i do n't even see any signs of any arthritis that i would've been suspecting i would like you to stay on two tylenol five hundred milligrams and two ibuprofen two hundred milligram tablets and i want you to take that three times a day and that's gon na help with both the pain and the inflammation i'm also gon na order some physical therapy for your your right knee and that physical therapy will help strengthen the lower extremities and make it give you a little bit of a balance and some they'll be able to recommend good running exercises for you i do wan na follow up with you in two weeks and see if we're getting better so let's no running for two weeks and if we're we're improving then we'll move on and probably start adding some additional activity does that sound like a plan [patient] yeah that does i i was curious so i will lay off the running for now can i you know lift weights and do like my squats and and those type of exercises at the gym [doctor] yeah absolutely and and those are good exercises but i'd like you to get that first physical therapy appointment in and they'll be able to talk with you on what the best exercises are for you to do [patient] okay got it [doctor] any questions [patient] hmmm no i do n't think so [doctor] okay thank you abigail and i'd like i said stop out at the desk and we'll make an appointment for two weeks [patient] okay thanks doctor [doctor] thank you

CHIEF COMPLAINT Right knee pain. SOCIAL HISTORY Patient reports she is an avid runner who enjoys participating in marathons. FAMILY HISTORY Patient denies any known family history of arthritis or other immune disease. REVIEW OF SYSTEMS Constitutional: Denies fever. Musculoskeletal: Reports right knee pain. VITALS Blood pressure: 120/60 mmHg Heart rate: 58 bpm Respiration: 14 No fever. PHYSICAL EXAM Respiratory - Assessment of Respiratory Effort: Normal respiratory effort. Cardiovascular - Examination: Normal pedal pulses in right knee. - Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs. Musculoskeletal - Examination: No clubbing, cyanosis, or edema. - Right knee: No pain with movement. No pain with strength testing. No erythema or edema. Small effusion. Tender to palpation over the lateral aspect of the knee. RESULTS X-rays of the right knee were obtained and reviewed in office today. These reveal well-maintained joint spaces. There is no evidence of any fracture or arthritis. ASSESSMENT AND PLAN 1. Right knee sprain. - Medical Reasoning: The patient is an avid runner and her symptoms appear to be the result of overuse. - Patient Education and Counseling: We discussed the nature of her diagnosis, as well as her x-ray results, in detail. I advised her that this is a common issue for runners and encouraged her to continue her strength training exercises. - Medical Treatment: She will take Tylenol 500 mg, 2 tablets, and ibuprofen 200 mg, 2 tablets, 3 times daily to reduce her pain and inflammation. We will also refer her to physical therapy to help strengthen her lower extremities, work on her balance, and demonstrate proper running exercises. She should avoid running for the next 2 weeks until her follow up visit, at which point we can consider adding some additional activity. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 2 weeks.

aci

D2N046

[doctor] okay so we are recording okay so okay so i understand you've so you've got a past medical history of type two diabetes and you're coming in and for evaluation of a newly diagnosed ovarian cancer so how are you doing today [patient] i do n't hear the question but i'm assuming that you when you say batcher so when i start talking about my dog and my three cats and all that those sort of things are not going to be included in the in the note [doctor] right i want you you can talk about those things yes [patient] okay [doctor] okay so with your newly diagnosed ovarian cancer so how are you feeling today how are you doing [patient] i'm doing pretty good depressed [doctor] little depressed i can understand it's a lot to take on is n't it [patient] yes [doctor] okay okay so lem me ask you some questions so what kind of symptoms were you having that prompted you your doctor to do the tests [patient] i was having severe pain and bleeding [doctor] okay now do you have other symptoms such as weight loss constipation vomiting or issues with urination [patient] no vomiting but constipation and weight loss [doctor] okay yeah that's understandable so do you have any children or have you ever been pregnant [patient] i'm sorry i did n't hear that part [doctor] do you have any children or have you ever been pregnant [patient] no to either one of those [doctor] okay so and do you know at what age you got your period and when you started menopause [patient] thirteen for my period and twenty eighth for menopause [doctor] okay do you take any oral hormone replacement therapy [patient] no [doctor] okay any history of endometriosis [patient] any history of what [doctor] endometriosis [patient] no [doctor] okay how about any family history of any gynecological cancers [patient] i was adopted [doctor] okay okay so i'm just gon na do a quick exam of your abdomen and then perform a vaginal exam okay [patient] okay [doctor] alright okay so i do feel the mass on the where to go here okay [patient] i did n't know you're gon na play a doctor today [doctor] i did okay okay so i do feel the mass on the left side but everything else looks good and on abdominal exam there is slight tenderness to palpation of the left lower quadrant no rebounding or guarding on vaginal exam there are no external lesions on the labia the vaginal vault is within normal limits the cervix is pink without lesions and on bimanual exam i appreciate a left adnexal mass and there is no masses on the right okay so now i reviewed the results of your abdominal ct which show a three centimeter left ovarian mass with an associated local localized lymph node involvement there is no evidence of gross peritoneal or metastatic disease so lem me tell you a little bit about my assessment and plan so for the first problem so i do think this is most likely ovarian cancer looking at your ct scan it looks like stage three a disease based on the lymph node involvement i want to start by sending off some blood tests like a ca-125 and hcg and afp and ldh these are just tests that help me to determine what type of tumor i'm dealing with and then i want you to undergo genetic counseling and testing to see if you have a genetic predisposition for developing ovarian cancer so this stage of ovarian cancer is treated by performing surgery followed by adjunct chemotherapy so this means we'll start chemotherapy after you've recovered from surgery okay so for the surgery i would perform a hysterectomy remove both ovaries and perform a lymph node dissection to remove the involved and involve lymph nodes as well as any other ones i see and i'll also send a sample of any tissue if there anything that looks suspicious at all and we'll be able to tell exactly what stage this is based on the pathology reports i then recommend chemotherapy with cisplatin and taxol and based on how the surgery goes i may want you to receive intraperitoneal intraperitoneal chemo which is done inserting a small tube into your belly for the chemo to go directly into your peritoneum now i know that was a lot sick in do you have any questions or [patient] am i gon na die [doctor] well that's a good question so based on what i see at this time i will we believe you have a favorable diagnosis prognosis and you're also still young and healthy which makes your prognosis even better and we do need to see a final pathology report to give you a definitive answer though okay [patient] alright alright

CHIEF COMPLAINT New patient evaluation of newly diagnosed ovarian cancer. FAMILY HISTORY The patient was adopted and has no knowledge of any family history. REVIEW OF SYSTEMS Constitutional: Reports unintentional weight loss Gastrointestinal: Reports abdominal pain and constipation. Denies vomiting. Genitourinary: Reports abnormal vaginal bleeding. Denies urinary issues. Psychiatric: Reports depression PHYSICAL EXAM Gastrointestinal - Examination of Abdomen: There is slight tenderness to palpation of the left lower quadrant. No rebounding or guarding. Pelvic - Examination: There are no external lesions on the labia. The vaginal vault is within normal limits. The cervix is pink without lesions. On bimanual exam, I appreciate a left adnexal mass. No masses on the right. RESULTS CT scan of the abdomen was reviewed and demonstrated a 3 cm left ovarian mass with associated localized lymph node involvement. There is no evidence of gross peritoneal or metastatic disease. ASSESSMENT AND PLAN 1. Ovarian cancer. - Medical Reasoning: Looking at her abdominal CT results, it appears to be stage IIIA disease based on the lymph node involvement. - Patient Education and Counseling: I explained to the patient that the typical approach to treating this stage of cancer is surgical intervention followed by adjunct chemotherapy. The procedure and subsequent chemotherapy plans were discussed in detail. Given that she is young and otherwise healthy, I reassured her that I believe her prognosis is favorable based on her current status, however, this is dependent on the final pathology report. All of her questions were answered. - Medical Treatment: I want to start by ordering several blood tests including a CA-125, hCG, AFP, and LDH. I also want her to undergo genetic counseling and testing to see if she has a genetic predisposition for developing ovarian cancer. I recommend we perform a hysterectomy and oophorectomy, as well as a lymph node dissection to remove any involved lymph nodes. Any concerning tissue will be biopsied and sent to pathology for staging. After she has recovered from surgery, she will start chemotherapy treatment with cisplatin and Taxol. We may also consider intraperitoneal chemotherapy. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

aci

D2N047

[doctor] hi billy how are you what's been going on the medical assistant told me that you're having some difficulty urinating [patient] yeah yeah i i did n't really wan na come in to talk about it's kinda weird but i think probably over the last six months i'm just not peeing right it just does n't seem to be normal [doctor] okay so let's talk a little bit about that now is your is your stream is your urination stream weak [patient] yeah i'd probably say so [doctor] okay and do you feel like you're emptying your bladder fully or do you feel like you still have some urine left in there when you when you finish [patient] most of the times i'm okay but sometimes if i stand there long enough i i can kinda go a little bit more so it's taking a while actually to just go to the bathroom [doctor] okay and are you waking up at night to go to the bathroom does it impact your sleep [patient] yeah i try to empty my bladder now right before i go to bed and and not drink anything but i'm still probably getting up three or four times a night to go to the bed [doctor] okay so you're getting up about three or four times a night and and how long has this been going on you said for about six months [patient] yeah six months to like this and it's probably been a little bit worse over the last six months and maybe it's been longer i just did n't want to bring it up [doctor] okay so you think it's been going on longer okay alright now how about have you had any burning when you urinate at all [patient] no it i do n't think it burns [doctor] no burning when you urinate okay and and any other any other issues any problems with your bowels any constipation issues [patient] hmmm no i i i had diarrhea last week but i think i ate something bad [doctor] okay and ever have you ever had any issues where you had what we call urinary retention where you could n't pee and you needed to have like a catheter inserted [patient] my gosh no [doctor] okay [patient] i'll do that [doctor] alright and have you ever seen a urologist i do n't think so you've been my patient for a while i do n't remember ever sending you but have you ever seen one [patient] i do n't think so [doctor] okay now tell me how are you doing with your with your heart when was the last time you saw doctor moore the cardiologist i know that you had the the stent placed in your right coronary artery about what was that twenty eighteen [patient] yeah sounds about right i think i just saw him in november he said everything was okay [doctor] he said everything was okay alright and so you have n't had any chest pain or shortness of breath you're still walking around doing your activities of daily living are you exercising [patient] kind of [doctor] kind of okay now from what i remember i remember you being a big college football fan are you as excited as i am that georgia beat alabama in the national championships [patient] yeah yeah i'm super excited [doctor] you do n't really seem that excited [patient] get the problem fixed because i have to be able to sit there and watch the whole game [doctor] yeah i i really do n't like nick saving i'm so i'm super happy that that the dogs pulled it out [patient] i do n't know if we can do friends anymore [doctor] are you in alabama fan [patient] maybe i'm actually originally not from georgia so [doctor] okay alright well i mean i i'm i'm a long horns fan but anyway well i digress let's talk a little bit about your diabetes how are how are you doing with your sugars are you watching your diet [patient] i'm trying to yeah i think they are okay [doctor] okay and are you still taking the metformin [patient] yep [doctor] you are okay alright now i wan na go ahead and just move on to a quick physical exam okay i'm gon na be calling out some of my exam findings and i'm gon na let you know what that means when i'm done okay alright i do have to do a rectal exam i apologize i'm just gon na be calling it out what what i what i appreciate okay so on your heart exam i do appreciate a slight three out of six systolic ejection murmur hurt at the left base on your lung exam your lungs are clear to auscultation bilaterally on your abdominal exam your abdomen is nontender and nondistended i do n't appreciate any masses or any rebound or guarding on your prostate exam i do appreciate an enlarged prostate i do n't appreciate any masses on physical exam so what what does that mean billy so that ultimately means that you know everything looks good you know you have that little heart murmur which i believe you you've had in the past but we're gon na go ahead and look into that you know your prostate seems a little bit enlarged to me on physical exam so let's talk about how we can go about and and remedy that okay so for your first problem of this you know difficulty urinating i wan na go ahead and just order some routine labs i wan na get a a psa that kind of that ultimately kinda looks for prostate cancer issues which i do n't think you have because we did n't really appreciate that on physical exam i wan na go ahead and we can try to start you on what we call flomax zero point four milligrams once a day you should take it at night because it can cause people to get a little bit dizzy if they take it in the morning so i would take it at night and i wan na go ahead and refer you to a urologist just to look into this more so we can go ahead and and get this problem solved for you okay i'm also gon na go ahead and just order some routine blood tests just to make sure that we are not missing anything do you have any questions about that and i wan na go ahead and order a urinalysis and a urine culture [patient] yeah so sounds good have you seen that commercial for that super batter prostate stuff does that work [doctor] well i think the data it's it's i'm not really sure if it works or not i'm not that familiar with it let's just go ahead and stick with flomax and that's why we are gon na refer you to the urologist so that they can go ahead and talk to you about you know the most current treatment options for you okay [patient] alright [doctor] alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that [patient] nope [doctor] okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns [patient] alright when is the urologist gon na call me [doctor] i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week [patient] sounds good [doctor] okay alright well great it was good to see you bye [doctor] i could just hit it and i can just talk and then i'm just

CHIEF COMPLAINT Difficulty urinating. MEDICAL HISTORY Patient reports history of coronary artery disease and diabetes. SURGICAL HISTORY Patient reports undergoing right coronary arter stent placement in 2018 by Dr. Moore. SOCIAL HISTORY Patient reports that he tries to exercise. He is a college football fan. REVIEW OF SYSTEMS Cardiovascular: Denies chest pain or shortness of breath. Gastrointestinal: Denies change in bowel movements. Genitourinary: Reports difficulty urinating. Denies dysuria or urinary retention. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular Slight 3/6 systolic ejection murmur heard at the left base. Gastrointestinal - Examination of Abdomen: Nontender and nondistended. No masses, rebound or guarding. Rectal - Examination: Enlarged prostate appreciated. No masses appreciated. ASSESSMENT AND PLAN 1. Difficulty urinating. - Medical Reasoning: The patient presents today with approximately a 6 month history of difficulty with urination. His prostate also felt slightly enlarged on exam today. - Patient Education and Counseling: The patient was advised that there were no concerning symptoms of prostate cancer appreciated on his physical exam today. - Medical Treatment: We will order routine labs including a PSA to rule out prostate cancer. We will also refer him to a urologist for further evaluation as well as order a urinalysis and urine culture. We will start him on Flomax 0.4 mg once at night to avoid dizziness. 2. Coronary artery disease. - Medical Reasoning: The patient had a 3/6 systolic ejection murmur heard at the left base on exam today. This has been heard on his exams in the past. - Medical Treatment: We will order an echocardiogram to follow up on his murmur. We will also order a lipid panel. He will continue Lipitor 40 mg a day, aspirin and metoprolol. 3. Diabetes. - Medical Reasoning: The patient is currently doing well with his diabetes. - Medical Treatment: We will continue him on metformin 1000 mg twice a day. A hemoglobin A1c will be ordered to see if any medication adjustments are needed. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS He will follow up in 3 to 4 weeks and is advised to call or message me in the patient portal if he has any concerns.

aci

D2N048

[doctor] alright brittany so i see that you are experiencing some right foot pain could you tell me what happened [patient] yeah well i was playing tennis and i was trying to you know volley the ball [doctor] mm-hmm [patient] it was like a double game and i was trying to volley the ball and i got in front of another player and actually ended up falling on top of my foot [doctor] alright [patient] and then yeah it kinda hurt i quickly then twisted my myself around her because i was trying to catch myself but then i started to feel some pain in my foot [doctor] mm-hmm okay have you ever injured that foot before [patient] yeah no sorry i injured my other foot before not this foot [doctor] okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing [patient] yeah that's fine [doctor] alright were you able to continue playing [patient] no i had to stop i actually it was like i had to be held from the field because i could n't put weight on my foot [doctor] i'm sorry okay so what have you been doing for the pain since then [patient] i wrapped it after a the game they had some ace wraps in their clubhouse and so i wrapped it up and then i iced it last night and i just kept it up on a pillow and then i took some ibuprofen [doctor] okay could you one more time when did this injury happen [patient] this happened about couple days ago [doctor] okay so did you say whether does the ibuprofen help at all [patient] yeah it helps a little bit but then you know it it you know after a while it wears out [doctor] okay and then have you experienced any numb numbness or tingling [patient] no no numbness [doctor] okay alright any loss in sensation [patient] no i mean i i can still feel like i can still feel my foot [doctor] okay alright that's good to hear so you were playing tennis is that what you normally do to work out [patient] i do i'm trying to learn but i can not afford tennis less lessons so me and my friends just hit the balls back and forth i do sleep [doctor] i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah [patient] that scares me [doctor] it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay [patient] okay [doctor] alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt [patient] no uh uh [doctor] okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions [patient] yeah do i have to do the surgery [doctor] so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with [patient] i just hate that word surgery doc [doctor] i know [patient] you know it scares me every time i mean especially with my foot i want to be able to walk again and so i just get really worried i mean how long is the procedure usually too [doctor] so it's actually [patient] have to be in the hospital [doctor] no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed [patient] i'm right handed [doctor] yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what [patient] i mean [doctor] uh uh [patient] does that mean i'm out for the rest of the season i mean i wan na be able to get back and play again i really am i'm getting a little better so i [doctor] mm-hmm [patient] i really wan na keep on playing my tennis with my friends but [doctor] yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there [patient] i suppose so [doctor] yeah [patient] okay [doctor] alright [patient] thank you [doctor] no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay [patient] okay [doctor] alright [patient] good [doctor] thank you [patient] thank you

HISTORY OF PRESENT ILLNESS Brittany Edwards is a 76-year-old female, right-hand-dominant, female who presents to the clinic today for the evaluation of right foot pain. The onset of her pain began 2 days ago, when she was playing tennis and was trying to volley the ball when she got in front of another player and fell on the dorsal aspect of her right foot. She states that she quickly twisted her foot because she was trying to catch herself. The patient reports that she was unable to continue playing secondary to the pain. She states that she wrapped her foot after the game and iced it last night. The patient adds that she kept her foot up on a pillow and took ibuprofen for pain. She denies any numbness. The patient denies any loss of sensation. The patient has a history of a left leg injury. REVIEW OF SYSTEMS Musculoskeletal: Reports right foot pain. Neurological: Denies numbness in the right foot. PHYSICAL EXAM SKIN: Warm NEURO: Normal sensation. MSK: Examination of the right foot: Bruising of the plantar and dorsal aspects of the foot. Associated swelling. Tenderness to palpation of the midfoot. Positive piano key test of the 1st and 2nd metatarsals. Warm to touch. Neurovascular intact distally. Capillary refill is less than 3 seconds. Strong dorsalis pedis pulse. Examination of the left foot: Brisk capillary refill to all digits and light touch intact. RESULTS 3 views of the right foot were taken. These reveal subtle dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases. There is the presence of a bony fragment in the Lisfranc joint space. ASSESSMENT Right foot pain, consistent with a Lisfranc fracture. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her x-rays revealed a Lisfranc fracture. We discussed treatment options for this and I have recommended that we proceed with surgical intervention. The plan is to proceed with a right foot ORIF and all indicated procedures. We went over the risk, benefits, and alternatives of the surgery. The risk include but not limited to continued pain, swelling, damage to surrounding tissue including nerves and blood vessels, numbness that could be permanent, infection, nonunion, malunion, failure of hardware, and need for further surgery. There is always a risk of amputation, heart attack, stroke, blood clots, pulmonary embolism, and death. There is a possibility of chronic pain and the inability to get back to the previous level of function. The patient wishes to proceed with the operation and she will follow up with me on the day of surgery. In the meantime, I have recommended that the patient attend formal physical therapy to strengthen her right foot.

aci

D2N049

[doctor] hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on [patient] and i've been in a lot of pain it started about i would say probably about three days ago [doctor] okay [patient] started having pain on my left back [doctor] okay [patient] and since then i continued to have pain it is traveling a little lower it's gotten little low but i definitely have not passed it yet and i'm just in so much pain [doctor] okay so is the pain that you're having is it constant or does it come and go [patient] it's constant [doctor] okay [patient] all the time i ca n't get comfortable [doctor] alright are you able to urinate [patient] i am and this morning i actually started seeing some blood [doctor] okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes [patient] i've had it for probably this might be my third time [doctor] third time alright [patient] yeah i have n't had one in a while but yeah this is my third time [doctor] okay so have you noticed any nausea chills fever [patient] no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous [doctor] okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain [patient] yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working [doctor] okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved [patient] yeah usually usually about about three four days to pass it yeah [doctor] right so this is this is the looks like this is the third day [patient] yeah [doctor] so we are getting close there [patient] okay [doctor] yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff [patient] i was i have n't been great about taking it but i did get the blood pressure cuff [doctor] so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running [patient] like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty [doctor] okay [patient] and then the bottom number has been between seventy and eighty okay that i mean that's not too bad i think when you were first diagnosed you were up there in the [doctor] the one eighties which was really high [patient] right [doctor] so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that [patient] trying my best but doc i really like my french fries [doctor] yeah [patient] like [doctor] we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help [patient] yeah some help could be helpful okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright [doctor] so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday [patient] i have and those those have been pretty good they are like in the low one hundreds [doctor] okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday [patient] i do [doctor] okay [patient] i do take it [doctor] that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain [patient] no chest pain [doctor] no chest pain are you having any belly pain [patient] the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain [doctor] no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt [patient] yes [doctor] okay i'm gon na press here on your back is that painful [patient] yes [doctor] alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound [patient] that sounds good and i i just i just want this pain to go away so thank you [doctor] okay no problem

CHIEF COMPLAINT Left-sided back pain. MEDICAL HISTORY Patient reports history of history of hypertension, diabetes, and kidney stones. MEDICATIONS Patient reports taking Tylenol, occasional ibuprofen, Norvasc 2.5 mg daily, and metformin 500 mg daily. REVIEW OF SYSTEMS Constitutional: Reports chills and decreased appetite. Denies fever. Cardiovascular: Denies chest pain. Gastrointestinal: Reports nausea. Denies abdominal pain. Genitourinary: Reports hematuria. Musculoskeletal: Reports left-sided back pain. VITALS Blood pressure is slightly elevated, likely due to patient's pain level. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi. Cardiovascular - Auscultation of Heart: Grade 2 out of 6 systolic ejection murmur, unchanged. Gastrointestinal - Examination of Abdomen: Tenderness to palpation of the abdomen. No rebound or guarding. CVA tenderness present at right flank. RESULTS Previous hemoglobin A1c is reviewed at 7.3. ASSESSMENT AND PLAN 1. Kidney stone. - Medical Reasoning: Patient presents today with symptoms consistent with kidney stones. She does have a history of kidney stones with this being her third episode. - Patient Education and Counseling: We discussed the importance of pushing fluids to help facilitate passing the kidney stone. - Medical Treatment: Prescription for oxycodone 5 mg every 6 to 8 hours as needed for pain was provided today. Tylenol is recommended for breakthrough pain. She will push fluids and has been provided with a urine strainer. Referral to urology was also provided due to her recurrent episodes. 2. Hypertension. - Medical Reasoning: Patient is currently stable and has not had any elevated readings. Her blood pressure was slightly elevated today, however, this is due to her current pain level. - Patient Education and Counseling: We discussed the importance of home blood pressure monitoring with the goal of at least 3 times per week. She was also advised on the importance of diet modification with limiting salt to 2300 mg daily. - Medical Treatment: Continue Norvasc 2.5 mg. Continue with home blood pressure monitoring 3 times per week. Limit salt intake to 2300 mg daily. 3. Diabetes. - Medical Reasoning: Patient is currently stable and has not had any elevated glucose readings. - Patient Education and Counseling: We discussed the importance of diet modification. - Medical treatment: Continue metformin 500 mg daily. Continue with home glucose monitoring before meals. Referral to a dietitian was provided. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

aci

D2N050

[doctor] hey mason good to see you today so let's see you here in my notes for evaluation of kidney stones your your pcp said you had some kidney stones so you got a referral over so can you tell me a little bit about that you know what happened when did you first notice them [patient] yeah it was about you know about a week ago and i was working down in the the barn with the horses and you know i was moving some hay but i developed this real sudden onset of pain in my right back and i thought it initially it was from throwing hay but it i broke out into a sweat i got real nauseated and that's when i went and saw my doctor and he ordered a cat scan and said that i had a kidney stone but you know that's i i've never had that before my father's had them in the past but yeah so that's that's how that all happened [doctor] okay so you said you had the pain on the right hand side does it move anywhere or radiate [patient] well when i had it it would it radiated almost down to my groin [doctor] okay [patient] not the whole way down but almost to the groin and since then i have n't had any more pain and it's just been right about there [doctor] okay and is the pain constant or does it come and go [patient] well when i you know after i found out i had a disk a kidney stone it came a couple times but it did n't last as long no i've been i've been straining my urine they told me to pee in this little cup [doctor] mm-hmm [patient] and i've been straining my urine and you know i do n't see anything in there [doctor] okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual [patient] no not really not really darker [doctor] okay so have you had kidney stones before and then you said your father had them but [patient] i've never had a kidney stone my dad had them a lot but i've never had one [doctor] okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means [patient] i have a stroke [doctor] can you repeat that [patient] i did i have a stroke [doctor] no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in the proximal right ureter and that's that duct that classes from your your kidney to down to your bladder there is no evidence of hydronephrosis that would mean that the stone is obstruct obstructing the ureter causing swelling in the kidney so there is there is no evidence of that so let's talk a little bit about my assessment and plan so you do have that kidney stone so right now i'm gon na recommend that we we have you push fluids just to help facilitate you urinating and passing the stone i'm gon na prescribe you some oxycodone five milligrams every six to eight hours for pain and you can continue to take tylenol between that for any breakthrough pain and you already have a strainer so that's good continue to use that and we can see continue that until the stone hasses and i'm also gon na order a bmp and your urinalysis and urine culture just to make sure that everything else is okay with you and based on urinalysis we can see if we need to prescribe you antibiotics see if you have any type of infection i do want to see you back in about one to two weeks and hopefully by that time you you passed the stone but if not we can discuss further treatment lithotripsy it's like a shock wave kinda breaks up that stone it's not it's not that invasive procedure but we can just we can discuss that if it has n't passed in that one to two weeks that sound good [patient] that sounds perfect dear too [doctor] alright [patient] thank you document [doctor] so i will see you in a week or so and hopefully you've passed that stone and i'll send my nurse in with that prescription [patient] okay thank you [doctor] thanks

CHIEF COMPLAINT Kidney stones. HISTORY OF PRESENT ILLNESS Mason Ward is a pleasant 80-year-old male who presents to the clinic today for the evaluation of kidney stones. The patient was referred from his primary care physician. The onset of his pain began 1 week ago when he was in his barn moving hay when he had a sudden onset of right back pain. The patient initially thought his pain was due to throwing hay; however, he broke out into a sweat and became nauseated. He was seen by his primary care physician, who ordered a CT scan and told him that he had a kidney stone. He denies having kidney stones before, but states that his father has a history of kidney stones in the past. He explains that when he had pain, which has now resolved, it would radiate almost to his groin. The patient describes the pain as intermittent after he found out it was a kidney stone. He explains that he has been straining his urine, but has not seen anything. He denies any hematuria. REVIEW OF SYSTEMS Musculoskeletal: Reports right back pain. VITALS Vitals look good, blood pressure and hear rate are within normal limits. Temperature is within normal limits. PHYSICAL EXAM MSK: Examination of the abdomen: No pain with palpation of the abdomen. No rebound or guarding. There is CVA tenderness on the right side. RESULTS The CT scan of the abdomen revealed a stone that is measuring 0.5 cm located in the proximal right ureter. There is no evidence of hydronephrosis. ASSESSMENT Right kidney stone. PLAN We reviewed the patient's CT results in detail today. I have recommended that we treat the patient conservatively. I have prescribed the patient oxycodone 5 mg every 6 to 8 hours for pain. He may continue to take Tylenol between the oxycodone doses for any breakthrough pain. The patient should continue to use the strainer when he urinates until the stone passes. I have also recommended that we obtain a BMP, urinalysis, and urine culture to evaluate for any signs of infection. INSTRUCTIONS The patient will follow up with me in 1 to 2 weeks to check on his progress. If his symptoms have not improved, we will discuss further treatment options including lithotripsy.

aci

D2N051

[doctor] hi jeremy how are you [patient] i'm really good thank you how are you [doctor] i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks [patient] yes [doctor] going away [patient] yeah it's been there gosh it's like six or so weeks right now and it's and it's on my right foot and it's just yeah it's just not going away i'm not sure if it maybe even gotten a little worse from when i first noticed it [doctor] okay and how long did you say it's going on for [patient] probably about [doctor] six eight weeks maybe [patient] okay and do you have any pain in your foot no no no pain at all okay now i know that you're a diabetic and you are on some insulin have your sugars been running okay yeah they have been running [doctor] okay [patient] you know on the most part they seem to be running a little higher than normal [doctor] your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine [patient] yes it it it definitely was higher than nine [doctor] okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or [patient] yeah i was you know i think initially i'm you know i was out in the backyard you know kind of you know doing some work and you know i know i you know i could've stepped on a nail or you know there was some other work but you know i'm always outside so i do n't know if that kind of led to anything or caused anything [doctor] okay alright and have you had any fever or chills [patient] no no no fever or chills you know i kinda you know get headaches pretty often i do n't know if that you know i do n't know if that's a stress or but you know always have like the tension headaches in the front [doctor] okay and do you have do you have neuropathy where you get like numbing and tingling in your feet [patient] occasionally yeah occasionally especially when it's like colder outside [doctor] mm-hmm kinda feels like it takes a little longer to [patient] warm up but yeah i kinda have some sensation in in all my extremities [doctor] okay alright and then are you are you a smoker or did you smoke [patient] i did back you know kind of years ago i did but yeah i have n't smoked anything in in good number of years [doctor] okay alright when did you stop smoking [patient] couple years ago maybe four or so years ago [doctor] okay alright and how many packs a day would you smoke [patient] gosh back then yeah was at least two [doctor] okay alright how many years did you smoke for like twenty [patient] yeah at least twenty yeah twenty plus years [doctor] okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk [patient] no no no no pain you know just kind of you know it's just i know that it's there [doctor] okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no [patient] no no you know it's you know i just kinda feel like i've been just trying to take it easy lately [doctor] mm-hmm [patient] but yeah most most of the stuff i've been doing is just kind of hanging around the house [doctor] okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin [patient] i am yes yeah i do the baby aspirin every day [doctor] okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything [patient] okay and do you have a podiatrist for your yearly foot exams [doctor] no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here [patient] no [doctor] there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help [patient] any questions [doctor] yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay [patient] sure [doctor] sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay [patient] okay perfect [doctor] alright [patient] perfect thank you so much [doctor] okay bye

CHIEF COMPLAINT Right foot ulcer. HISTORY OF PRESENT ILLNESS Jeremy Roberts is a 79-year-old male who presents today for evaluation of a right foot ulcer. He reports an ulcer on his right foot has been present for approximately 6 to 8 weeks. He first noticed the ulcer after working outside. There is no associated pain, however, he feels the ulcer may have worsened from when he first noticed it. He denies experiencing any fevers or chills. He does however experience tension headaches quite frequently. He denies any pain in his calves when he walks. At this time the patient does not have a podiatrist for yearly foot exams. He is a diabetic and takes insulin. His blood sugar has been running higher than normal and his last hemoglobin A1c was higher than 9. Occasionally he will also experience numbness and tingling in his feet, especially with colder weather. In terms of his heart disease, the patient sustained a heart attack in 2018 and underwent stent placement at the right coronary artery. He is currently taking aspirin 81 mg daily. He denies chest pain or shortness of breath. MEDICAL HISTORY Patient reports history of diabetes and heart disease. He sustained a heart attack in 2018. SURGICAL HISTORY Patient reports undergoing stent placement at the right coronary artery. SOCIAL HISTORY Patient reports he is a former smoker. He previously smoked 2 packs a day for 20 years and was able to stop smoking approximately 4 years ago. Currently he is not very active but he does work around the house. MEDICATIONS Patient reports taking aspirin 81 mg daily and insulin. REVIEW OF SYSTEMS Constitutional: Denies fevers and chills. Cardiovascular: Denies chest pain. Respiratory: Denies dyspnea. Skin: Patient reports right foot ulcer. Neurological: Patient reports headaches and numbness and tingling in feet. VITALS No fever. Blood pressure: 127/80 Heart rate: 60s PHYSICAL EXAM CV: 2/6 systolic ejection murmur heard at the left base. RESPIRATORY: Clear to auscultation bilaterally NECK: No jugular venous distention or carotid bruits MSK: Examination of the right lower extremity: No palpable dorsalis pedis or posterior tibial pulses. There is a 2 x 3 cm ulcerated lesion on the right lateral foot near the 5th metacarpal metatarsophalangeal joint. No associated cellulitis. No pain to palpation of the right foot. There is associated granulation tissue and some slight purulent discharge from the wound. ASSESSMENT 1. Non-healing ulcer, right foot 2. Diabetes 3. Coronary artery disease PLAN After reviewing the patient's examination findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his right foot ulcer is fairly sizable and will require wound care. I advised him that the ulcer does not appear to be healing and that further studies will be needed to assess if he has adequate blood supply to heal his foot wound. He was advised that due to his diabetes it is possible surgical intervention such as stent placement or bypass surgery may be required to improve his blood supply. I also advised him that I believe we will be able to heal his wound. At this time, I have recommended continued wound care and for him to also continue taking aspirin 81 mg daily. We will order an arterial ultrasound of the lower extremities. He will also be referred to podiatry for a consult. Regarding his diabetes, this appears to be unstable as the patient reports his last hemoglobin a1c was greater than 9 and is now experiencing a non-healing right foot ulcer. We discussed the importance of blood sugar control as this will impact his wound healing. At this time, I have recommended that he follow-up with his primary care physician for further care. The patient's coronary artery disease is currently stable. It is recommended that he continue to take his statin as prescribed. I will contact his cardiologist for medical clearance should surgical intervention be required for his non-healing right foot ulcer.

aci

D2N052

[doctor] so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you [patient] sure i've been having some back pain on my right side it's been lasting for about a week now [doctor] okay [patient] and i also started to see some blood in my urine [doctor] okay so on the right side so does that pain does it move anywhere or is it just kinda stay in that that one area [patient] yeah it's moved down a little bit on to my right lower side a little bit [doctor] side okay so how would you describe the pain is it constant or is does it come and go [patient] it's pretty constant [doctor] okay did you notice any pain when you're urinating i know i know you say you you saw you see blood but any pain with that [patient] no no real pain when i'm when i'm peeing at all [doctor] okay so have you taken anything i know have you tried like azo or any of that to [patient] i took some ibuprofen that helped a little bit [doctor] okay [patient] but it still hurts even with ibuprofen [doctor] alright have you noticed any nausea vomiting fever chills [patient] i have n't thrown up but i felt a little bit nauseated [doctor] little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but [patient] yeah my my dad had kidney stones i think he has passed a couple of them i'm not quite sure [doctor] alright and have you had any in the past or is this your first one [patient] this is my first time i've never had this before [doctor] okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that [patient] yeah yeah i had some pain over the weekend i saw my pediatrician this morning so they sent me over here they were concerned that i might have a kidney stone [doctor] okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain [patient] not so much but i i got to participate a little bit i opened some eggs i just did n't go run around and find them [doctor] okay well i i'm lucky enough my friends had an adult easter hag hunt for me and so i was able to find a couple eggs yesterday myself so i i'm glad you were able to get a few of them alright so let's do that that physical exam on you so your vitals look good you do n't have any fever your blood pressure heart rate is fine so when i press here on your belly does that hurt [patient] a little bit yeah [doctor] a little bit alright so on your exam of your abdomen there is mild pain and tenderness to palpation of the abdomen there's no rebound or guarding there is cva located near your flank tenderness on the right so that means that everything looks good but you do have what seems to be some inflammation of your kidney okay so we we were able to get a ct of your your side and it showed that you do have a stone measuring point five centimeters in size and it's located in the proximal right ureter and so that's that duck that passes from your kidney to your bladder alright i do n't see any evidence of hydronephrosis so that means that there's not obstructing ureter causing swelling in your kidney which is which is pretty good so let's talk a little bit about my assessment and plan so you do have that kidney stone on the right so what i'm recommending is i want you to push fluids just to help facilitate you passing that stone alright have you been taking in have you been drinking enough water do you think so far [patient] probably not enough i drink some but [doctor] okay yeah i i want you to to drink try drink as much as possible just to see if we can get you hydrated and pass the stone what i'm gon na do is i'm gon na prescribe you ibuprofen eight hundred milligrams you can take that as needed for pain i know you said you were in that much pain just in case it does start to move you're in pain i want you to take the ibuprofen i'm also gon na give you a strainer for you to strain your pee so we can see you wan na know when that that stone does pass gon na order a bmp and a urinalysis and a urine culture and based on what the urinalysis shows we can decide if i can decide if i need to put you on antibiotics if you do have an infection of some kind and i wan na see you back in about a week to two weeks and if you're still having symptoms we can discuss further treatment such as a lithotripsy and it's it's a mainly minimally invasive procedure where we use shock waves to try to break up that stone but otherwise do you have any other questions for me [patient] no i do n't think so [doctor] alright so we will see you back in a week or two and i'll have my nurse come in with that prescription and hopefully with all the treatment you'll be able to pass the stone okay alright

HISTORY OF PRESENT ILLNESS Anna Diaz is a pleasant 29-year-old female who presents to the clinic today for the evaluation of right-sided back pain. For approximately 1 week, the patient has been experiencing constant right-sided back pain that radiates down to her lower right side, as well as hematuria and nausea. Her primary care physician was concerned for possible kidney stones and subsequently referred her here for further evaluation. She denies any pain with urination or vomiting, but admits that she has likely not been drinking enough water. The only treatment she has tried so far is ibuprofen with minimal pain relief. Although she denies any personal history of kidney stones prior to this occurrence, she explains that her father has had kidney stones in the past. REVIEW OF SYSTEMS Constitutional: Negative for fever. Gastrointestinal: Positive for nausea. Negative for vomiting. Genitourinary: Positive for hematuria VITALS Vitals are normal. Blood pressure is normal. Heart rate is normal. PHYSICAL EXAM GI/GU: Mild pain and tenderness to palpation of the abdomen. No rebound or guarding. There is CVA located near her flank with tenderness on the right. RESULTS CT scan of the abdomen was reviewed today and revealed a kidney stone measuring 0.5 cm in size, located in the proximal right ureter. There is no evidence of hydronephrosis. ASSESSMENT Kidney stone, right side. PLAN After reviewing the patient's examination and CT results, I discussed the findings with the patient. The CT scan revealed a 0.5 cm kidney stone in the proximal right ureter. I advised her to drink plenty of fluids, as much as possible, to help facilitate passing of the stone. She was provided with a urine strainer so she can see if and when the stone passes. Given that over-the-counter ibuprofen is not providing significant relief, we will send in a prescription for ibuprofen 800 mg to help with her pain. I'm also going to order a BMP, urinalysis, and a urine culture for further evaluation. Depending on the results of the urinalysis, we may need to start her on antibiotics. I want to see her back in 2 weeks. If she is still symptomatic at that time, we may need to consider further treatment such as a lithotripsy. This procedure was explained to the patient. INSTRUCTIONS Follow up in 2 weeks.

aci

D2N053

[doctor] so barbara i i know you are here for some itchy scalp pain can you tell me a little bit about how you're doing [patient] yeah it's still quite a problem you know something i've been suffering with for so long now it's still quite itchy and it's really embarrassing too because i'll have dandruff so much like all over me but but i just ca n't stop itching [doctor] okay when did you first notice this [patient] i wan na say it's been a while but probably worsening in the past like six months or so [doctor] okay okay and have you seen ever noticed any rashes either when it first started or intermittently anywhere else [patient] on my body no not really [doctor] okay okay just mainly up underneath your on your scalp there uh and i can i can see that man that looks really itchy and scaly have you died your hair recently or used any other chemicals you you know like a new hair spray or gel [patient] nothing new i mean i do dye my hair but i've been doing that for years now but otherwise i do n't really use a lot of products in my hair [doctor] yeah i you know it's funny you say that because i keep saying i earned this gray hair and i'm gon na keep it so yeah have you tried any over the counter treatments i know there is a lot out of there something you know like a t gel or any of those other have those helped [patient] yeah i did that i did head and shoulders i even tried some castor oil and but none of them really seemed to be helping [doctor] okay okay let's talk about some other symptoms any joint pain fever weight loss [patient] not that i can recall i've been pretty good otherwise [doctor] okay good and going back you know to your grandparents has anybody else in the family had similar symptoms that you're aware of [patient] no well maybe my sister [doctor] maybe your sister okay [patient] yeah maybe my sister i mean i know she'll is no one has as bad as i do but she does report like just having a dry scalp [doctor] okay okay now you know a lot of times we can see this with you know high levels of stress has there been any new mental or emotional stressors at work or at home [patient] not really i mean it's basically the same things [doctor] okay yeah i yeah we have a lot of that yes so let me go ahead and and look at this a little closer here the first off i wan na tell you the the vital signs that the my assistant took when you came in your blood pressure is one thirty over sixty eight your heart rate was ninety eight and your respiratory rate was eighteen so those all look good and appear normal and your temperature was ninety seven . seven and that is all normal now when i look at your scalp here i do notice that you have demarcated scaly erythematous plaques and that's just kind of explaining technically what's going on those patches and they're they're in a patchy format they're diffusely present across the back of your skull and that's probably why you you see all that that that white dander you know on your on your your clothes as you go through the day now lem me talk a little bit about my impression and plan i think that you have a scalp psoriasis and let's and here is my thoughts on that what i would like you to use is to use clobetasol that's a zero . zero five percent solution and i want you to use that twice daily on the the affected areas of your scalp so you're just gon na put this on and just kinda gently rub it in now i know to do it twice daily is going to be difficult but if you can do it first thing in the morning when you get up and then before you go to bed you know get a shower and before you go to bed that will be great i want you to continue to use t-gel shampoo that you listed when you first came in that's a very good solution shampoo for that and that will help with controlling a lot of this now there is no cure for this unfortunately and flareups can be unpredictable but we see that you know not a we do n't have a great finger on what causes the flare ups but i'm gon na give you some steroids that will help and we're gon na have to manage that on a ongoing basis but when you get do get a flare up i want you to be using these flare steroid that i give you as we go through that and then i wan na see you back here in three months or sooner if it gets significantly worse do you have any questions for me [patient] no okay so i'll just use that steroid solution and then just as needed if it's really bad but then otherwise just use the t gel [doctor] yeah i want it's exactly what i want you to do i want you to use that that solution twice daily when you get that flare but then other than that just continue to use that t-gel shampoo [patient] alright [doctor] okay i'm gon na have my nurse come in and get you discharged but i the we will see you again in three months or and again please if it gets worse please do n't hesitate to call me and come in sooner [patient] alright perfect thank you [doctor] thank you [patient] okay bye

CHIEF COMPLAINT Itchy scalp pain. REVIEW OF SYSTEMS Constitutional: Denies fever or weight loss. HENT: Reports scalp pain Musculoskeletal: Denies joint pain. Skin: Reports itchy scalp Denies any rashes. VITALS BP: 130/68. HR: 98. RR:18. Temperature is 97.7 today. PHYSICAL EXAM Integumentary - Examination: Scalp reveals demarcated scaly, erythematous plaques. They are patchy in format and diffusely present across the back of the skull. ASSESSMENT AND PLAN 1. Scalp psoriasis. - Medical Reasoning: The patient presents today with symptoms similar to scalp psoriasis. - Patient Education and Counseling: Nature of the diagnosis was discussed as well as treatment options. Patient was advised there is no cure for this. Patient was counseled on how to apply clobetasol 0.05%. - Medical Treatment: Prescription for clobetasol 0.05% solution twice daily provided. Continuing using T/Gel shampoo. Prescription for steroids provided to be used for flare ups. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow-up in 3 months or sooner if her conditions worsen.

aci

D2N054

[doctor] hey elijah how are you [patient] i'm doing okay [doctor] so i see here that your primary care provider sent you over it looks like you were doing some yard work yesterday and dropped a landscape brick on your foot can what so what's going on with your right foot today [patient] it's a little sore today but you know i hurt my foot before but this is the first time where i'm actually being seen for it [doctor] okay so you say you've injured your right foot before tell me a little bit about that injury [patient] twenty years ago i broke my ankle i had to put in a cast but that seems to be okay but you know sometimes it'll give me trouble once in a while it feels a little sore it swells up at times [doctor] okay [patient] and my other ankle too is sore sometimes and i've had surgery for that too and you know one of those things where you know it might give out once in a while but i'm not sure that's related to what the you know break dropping on my foot but you know either way my foot's a little sore [doctor] okay alright so when you dropped that brick on your foot were you able to get up and keep working or did you have to get off your you know not stop weightbearing and and get off that foot can you tell me a little bit about after the traumatic incident [patient] i you know it was a little sore i called a few names you know god damn why is this in my foot but you know i kept working putting it around a little bit but now it's got swollen so i got to see my doctor he told me i had to go see you here i am so tell me what's going on with it [doctor] so what have you been doing for the pain since the initial insult [patient] lucken it up [doctor] okay have you taken any medications safe for example tylenol or ibuprofen for the pain [patient] no i feel like taking the medicine [doctor] okay and then just out of curiosity you said you were doing some landscaping have you been over to landscapes warehouse new here in town my wife and i were just over there this last weekend and picked up a whole bunch of stuff you had a chance to make it over there yet [patient] no not yet i heard about it though i might have to make a trip once my foot heals [doctor] alright that sounds good now just out of curiosity can you rate your pain for me right now zero being none ten being the worst pain you've ever been in your life [patient] eleven out of ten [doctor] okay and then have you experienced any numbness or tingling of that foot since the incident [patient] yeah the whole foot is numb [doctor] okay [patient] but been now for a long time [doctor] okay i'm gon na do a quick physical exam now your vitals look good and i would like to do a focused exam of your right foot the there is some bruising on the bottom part of your foot and on the top part as well and i do appreciate the associated swelling and i also recognize that you do have tenderness to palpation for midfoot now for your neurovascular exam of your right foot your capillary refill is brisk in less than three seconds i do note a strong bounding dorsalis pedis pulse with motor and sensation is intact for that foot i also like to call out the fact that it matches bilaterally which is important i'm gon na go ahead and review the diagnostic imaging results so we did a x-ray of that right foot and i do notice dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and presence of bony fragments so let me tell you a little bit about my assessment and plan now your right foot pain is due to a lisfranc fracture which is a fracture to your second metatarsal bone and the top of your foot this is where the metatarsals meet those cuboids okay so it where the bones come together in your foot now there are a lot of ligaments in your foot so i do want to order an mri just to assess if there is any injuries to those ligaments now based on your exam and looking at the x-ray you're most likely going to need surgery now the reason why this is important is if we have poor bone alignment or ligament healing you can this can lead to losing the arch in your foot you could becoming flat-footed and also developing arthritis now what's gon na be key here is the surgery is going to allow those bones and ligaments to heal properly we are going to put them back into place using plates and screws now the key thing is going to be it's going to be outpatient surgery so it's going to be same day i'll see you in the morning and then you'll be discharged home that evening and we will do a follow-up i wan na see you in twenty four hours post procedure but then i'll see you again in two weeks you're gon na be in a cast and i'm gon na have you use crutches you're not gon na be able to weight-bear on that foot for six to eight weeks what we'll do is we'll advance your ambulating gradually based on how you heal and based on how you tolerate the procedure i know i have covered a lot of material quickly but this is really gon na be the best course of action for you to have a good outcome now do you have any questions come answers concerns before i have the nurse come in finish the paperwork and get you set up for your procedure which we are going to do tomorrow if you're agreeable to that [patient] what about putting in a cast can i just stay in the cast [doctor] you could but what we found is the best outcome is aligning those bones with plates and screws to make sure that they heal properly so you have the best outcome possible [patient] so if the surgery is going to be tomorrow when am i going to get my mri [doctor] so what what we will do is the good news is we have an outpatient mri facility downstairs and i'm going to send the order down and we'll get you your mri this afternoon [patient] can i think about it and we have some time [doctor] sure [patient] okay [doctor] alright thanks elijah

CHIEF COMPLAINT Right foot pain. HISTORY OF PRESENT ILLNESS Elijah Reyes is a pleasant 45-year-old male who presents to the clinic today for the evaluation of right foot pain. The patient was referred by his primary care physician. He sustained an injury yesterday when he dropped a landscape brick on his right foot while doing yard work. He was able to get up and continue working after the injury. He rates his pain level as an 11 out of 10. The patient also reports numbness in his entire right foot, which has been present for a long time. The patient denies taking any medication for pain. The patient reports he fractured his right ankle 20 years ago. He received non-operative treatment with casting. He has experienced intermittent soreness and swelling in his right ankle since then. The patient reports surgical history of his left ankle. He continues to experience soreness and occasional giving way of the left ankle. MEDICAL HISTORY Patient reports history of a right ankle fracture 20 years ago. SURGICAL HISTORY Patient reports history of left ankle surgery. REVIEW OF SYSTEMS Musculoskeletal: Reports right foot pain, right ankle soreness and swelling, and left ankle soreness and instability. Neurological: Reports right foot numbness. VITALS All vital signs are within the normal limits. PHYSICAL EXAM CV: Capillary refill is brisk in less than 3 seconds in the right foot. Strong bounding dorsalis pedis pulse. NEURO: Normal sensation. Right foot motor and sensation are intact and equal to the contralateral side. MSK: Examination of the right foot: Bruising on the plantar and dorsal aspects of the foot. I do appreciate associated swelling. Tenderness to palpation over the midfoot. RESULTS An x-ray of the right foot was obtained and reviewed today. It demonstrates dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases and presence of bony fragments. ASSESSMENT Right foot pain, due to a Lisfranc fracture. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding his current symptoms. We discussed treatment options and I have recommended that we proceed with a right foot ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I advised him that this procedure will be performed in an outpatient setting and he will be discharged home that same evening. He will then follow up with me 24 hours post procedure, and again 2 weeks later. I explained that he will be placed in a cast and will remain non-weight-bearing for 6 to 8 weeks. He will use crutches while ambulating and we will advance his weight-bearing gradually based on how he tolerates the procedure. I have also recommended that we obtain an MRI of the right foot to further assess the ligaments. I explained to him that if he has poor bone alignment or ligament healing, this can lead to losing the arch in his foot causing pes planus and developing arthritis. I will send an order to the outpatient MRI facility downstairs for him to obtain the MRI this afternoon. The patient wishes to think over his options before proceeding with the operation.

aci

D2N055

[doctor] karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you [patient] i'm okay i guess [doctor] hey dad how are you doing [patient] hey doc i am okay yeah karen has been having this eye twitch i noticed a couple of weeks ago when i talked to her pediatrician and they told me to come see you [doctor] okay alright so karen have you felt the twitch [patient] yeah well i mean i feel my face sometimes [doctor] yeah and do you have any pain when it happens [patient] no it it does n't really hurt but i noticed that dad looks real nervous when it happens [doctor] yeah i i i can understand that's because he loves you do you feel the urge to move your face [patient] sometimes and then it moves and then i feel better [doctor] okay okay and so so dad how often are you seeing the twitch on karen [patient] i do n't know i mean it varies sometimes i see it several times an hour and there is other days we do n't see it at all until sometimes late afternoon but we definitely notice it you know everyday for the last several weeks [doctor] okay so karen how is how is how is soccer [patient] i like soccer [doctor] yeah [patient] yeah dad dad takes me to play every saturday [doctor] okay [patient] it's it's pretty fun but there's this girl named isabella she she plays rough [doctor] does she [patient] she yeah she tries to kick me and she pulls my hair and [doctor] oh [patient] sometimes she's not very nice [doctor] that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson [patient] yeah and and then sometimes after soccer we we go and i get mcdugge's and it and it's it makes for a nice day with dad [doctor] is that your favorite at mcdonald's in the the mcnuggates [patient] not not really but they are cheap so [doctor] okay alright well you you made dad happy at least right [patient] yeah that's what he says because i'm expensive because i want dresses and dogs and stuff all the time [doctor] yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens [patient] no i mean when it happens she just continues playing or doing whatever she was doing when it happens [doctor] okay alright has she has she otherwise been feeling okay since this started has she been acting normally [patient] i i'd say she seems fine i mean she has been eating well and playing with her friends and she goes about her normal activities really [doctor] okay good [patient] never even though anything was going on [doctor] okay alright good so has has karen had any seizures in the past [patient] no [doctor] no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching [patient] well no uh it's just her face [doctor] okay [patient] i mean the whole side of her face moves when it happens it seems like it several seconds and then it finally stops and she just seems to be blinking frequently and and and you know wait a minute i i did make a video so you can see just in case it does n't do it during the visit [doctor] okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome [patient] well no history of seizures but i i i never heard of that tourette thing [doctor] yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger [patient] really i had nobody in our family got anything like that [doctor] okay now tell me have you noticed any other symptoms how about like fever or chills [patient] no [doctor] okay coughing headache [patient] ma'am [doctor] okay how about any problems with karen's sleep [patient] nope [doctor] okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay [patient] okay [doctor] alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there [patient] mm-hmm [doctor] does that feel the same [patient] yeah [doctor] okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator drift sensation is intact reflexes are two plus and symmetric at the biceps triceps knees and ankles so this means everything looks good karen [patient] that's great [doctor] good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school years and tics can also include things like shoulder shrugging facial grimacing sniffling excessive throat clearing and uncontrolled vocalization i can say that essentially they're brief sudden and involuntary motor movements now we do n't have a full understanding of the cause of the tics but they typically occur around five to ten years of age but most ticks go away on their own and they disappear within a year so these are what we call transient tics and the best thing to do is ignore the tics so it does n't seem to be bothering karen and she seems to be doing well in school and activities so it may wax and wane over time but you might notice it more towards the end of the day when the child is tired so you may also you know see it if they're stressed so that's why it's important to just ignore it now when you draw attention to the tick it does make the child conscious so that can make the tic worse so we want to be careful again just to to kind of not to draw too much attention on it and do you have any questions for me [patient] so you mean you're telling me you do n't think he had a seizure or a bit or nothing [doctor] yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards [patient] so you're not recommending any kind of treatment there is no pill or cream or nothing [doctor] not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay [patient] alright alright sounds good [doctor] alright thank you you guys have a good day [patient] doctor [doctor] bye karen

CHIEF COMPLAINT Right eye twitch. SOCIAL HISTORY The patient plays soccer every Saturday, however she has noted that there is a girl that tries to kick her and pulls her hair. FAMILY HISTORY Patient's father reports that they do not have a family history of seizures or Tourette's syndrome. REVIEW OF SYSTEMS Constitutional: Denies fever, chills, or changes in appetite. Eyes: Reports right eye twitch. Denies right eye pain. Respiratory: Denies cough. Neurological: Denies headaches or sleep disturbances. PHYSICAL EXAM Neurological - Orientation: Alert and oriented x3. Speech is clear and fluent. Gait is steady. Heel toe walking is normal. Cranial nerves grossly intact without focal neurologic findings. No pronator drift. Sensation is intact. Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles. ASSESSMENT AND PLAN 1. Transient tics. - Medical Reasoning: The patient's father provided a video today as she did not have a twitch in office. It appears the patient is experiencing a tic. - Patient Education and Counseling: Nature of the diagnosis was discussed today with the patient and her father. I advised eye tics are very common in children and as many as 1 in 5 children have a tick during their school years. We discussed tics can also include things like shoulder shrugging, facial grimacing, sniffling, excessive throat clearing, and uncontrolled vocalization. I explained that essentially they are brief, sudden and involuntary motor movements and that we do not have a full understanding of the cause. We also discussed that they typically occur around 5 to 10 years of age and mostly resolve on their own within a year. Dad was advised that treatment is not recommended as they do not appear to be bothering Karen and she continues to do well in school and activities. Additionally, we discussed avoiding drawing attention to the tic as it may cause Karen to feel self-conscious and increase the severity of the tic. - Medical Treatment: None at this time. Patient Agreements: The patient's parent understands and agrees with the recommended medical treatment plan. All questions were answered.

aci

D2N056

[patient] alright thanks for coming in today i see on my chart here that you had a bunch of lower respiratory infections so first tell me how are you what's going on [doctor] you know i'm doing better now but you know last week i was really sick and i just have had enough like i was coughing a lot a lot of mucus even had some shortness of breath and even a low-grade fever [patient] wow that is a lot so what did you do for some of those symptoms [doctor] you know i ended up drinking a lot of fluid and taking some robitussin and i actually got better over the weekend and now i'm feeling much better but what concerns me is that i i tend to get pneumonia a lot [patient] okay so when you say a lot like how frequently does it occur i would say it seem honestly it seems like it's every month or every other month especially over the past six six months that i just keep getting sick and i usually will end up having to go to my primary care doctor or [doctor] urgent care and i'll get prescribed some antibiotics and one time i actually ended up in the emergency room [patient] wow and how long do your symptoms normally last for [doctor] you know it could be as few as like a couple of days but sometimes it could go even up to a week [patient] mm-hmm you mentioned that you are a farmer did you do you notice that your symptoms occur while doing certain things on the farm [doctor] you know i was trying to think about that and i've been working on the farm for some time but the only thing i can think about is that i've been helping my brother out and i've been started like unloading a lot of hay which i do n't usually do and i wan na say that my symptoms actually start the days that i'm unloading hay [patient] alright do you wear a mask when you're unloading hay [doctor] no i do n't do that [patient] okay [doctor] none of us do [patient] okay yeah so like that your brother does n't either [doctor] no i'm the only one who seems to be getting sick [patient] alright so i know you said you were trying to like help out your brother like what's going on with him [doctor] you know we've just been getting really busy and so he has been working around doing other things so i've just been helping him just cover the extra load [patient] mm-hmm okay alright do you have any other siblings [doctor] yeah there is actually ten of us [patient] wow okay that's that's a lot of siblings [doctor] yeah i'm okay [patient] maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place [doctor] yeah we do n't need to hire any i mean have anyone else this is our family [patient] you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies [doctor] no no i have never had any problems with allergies [patient] okay and do you smoke [doctor] i do n't smoke [patient] do you live with anybody who does [doctor] i do not [patient] okay alright so okay so now i i wan na go ahead and do my physical exam i'm gon na call out some of my findings just to make sure that i'm documenting everything and if you have any questions about what it is that i'm saying please feel free to ask okay [doctor] okay [patient] so i reviewed your vitals and you appear to be breathing a little fast your respiratory rate is twenty but but your oxygen is you're satting kind of fine at ninety nine percent on room air so i'm not too worried about that on for on your heart exam i do you have a regular rate and regular rhythm i do not appreciate any murmurs rubs or gallops on your lung exam you know i do you do have some fine rales on your lung exam but no wheezes and on your musculoskeletal exam i do not appreciate any clubbing of your fingers so for your results i did review the results of your chest x-ray and i noticed some round glass opacities so let me tell you a little bit about like my assessment and plan for your first problem of recurrent lung infections your symptoms seem consistent with a condition we call hypersensitivity pneumonitis in your case another name is farmer's lung which you know is appropriate considering your job this could be caused by bacteria and or mold that is found in the hay when you inhale it it leads to an allergic reaction in your lungs this is why your symptoms occur every time you move hay for your current symptoms i'm gon na prescribe you a a course of an oral steroid this will help to decrease the inflammation that is occurring in your lungs i will also be ordering a cat scan of your lungs which will help confirm the diagnosis as as well a pulmonary function test to assess how severe your respiratory impairment is it would be best if you could eliminate your exposure to the hay or prevent further to prevent further damage to your lungs however if you are unable it's very important that you wear a respirator when moving hay around i know that that was a lot of information i think it boils down to pull in more of your siblings to help work around but do you have any questions [doctor] yeah so is this gon na help so i do n't keep getting sick [patient] so ideally what we are doing i think this is the best course of action to deal with the deeper problem right of these infections and to kind of like clear up the pneumonia everything seems to hint on so what we're gon na do is treat your current infection we're going to either prevent you from being around hay or make it so that it's safe for you to be with hay and then we're gon na see like what we need to do moving forward does that help [doctor] okay it does [patient] alright [doctor] thank you [patient] okay no problem [doctor] alright

CHIEF COMPLAINT Recurrent lung infections. SOCIAL HISTORY Patient reports he is a farmer. He denies smoking or living with anyone who smokes. ALLERGIES Patient denies history of seasonal allergies. REVIEW OF SYSTEMS Constitutional: Reports low-grade fever. Respiratory: Reports shortness of breath and productive cough. VITALS Respiratory rate: 20 breaths per minute. Pulse oxygenation: 99 percent on room air. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Some fine rales were noted. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs. Musculoskeletal - Examination: No clubbing. RESULTS X-ray of the chest was reviewed today and shows some round glass opacities. ASSESSMENT AND PLAN 1. Recurrent lung infections. - Medical Reasoning: The patient's symptoms seem consistent with hypersensitivity pneumonitis. He is a farmer and has been moving hay quite frequently recently. - Patient Education and Counseling: The nature of the diagnosis was discussed with the patient. I explained that hypersensitivity pneumonitis could be caused by bacteria and/or mold that is found in the hay. We discussed that when inhaling this, it leads to an allergic reaction in the lungs, which would explain why symptoms occur every time he moves hay. He was advised that it would be best to eliminate his exposure to hay in order to prevent further damage to his lungs, however, if he is unable to do this then it would be recommended that he wear a respirator when working. Questions were invited and answered today. - Medical Treatment: A course of oral steroids were prescribed today to help decrease his lung inflammation. CT of the lungs will also be ordered today to confirm the diagnosis. A pulmonary function test was also ordered to assess the severity of his respiratory impairment. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

aci

D2N057

[patient] hi good afternoon joseph how are you doing today [doctor] i'm doing well but my my big toe hurts and it's a little red too but it really hurts okay how long has this been going on i would say you know off and on for about two weeks but last week is is when it really became painful i was at a a trade show convention and i could n't walk the halls i could n't do anything i just had to stand there and it really hurt the whole time i was there [patient] okay does it throb ache burn what kind of pain do you get with it [doctor] it's almost like a throbbing pain but occasionally it becomes almost like a a sharp stabbing pain especially if i move it or spend too much time walking i i find myself walking on my heel just to keep that toe from bending [patient] okay sorry i got a text and [doctor] well that's okay you know what i i you know i what i really you know i love to ride bikes have you you ride bike at all [patient] no i hate riding a bike i'm more of a runner [doctor] my gosh i love to ride i ride the lot of rails the trails i mean i go all the last year i put in over eight hundred miles on rails the trails [patient] yeah those those are nice [doctor] yeah [patient] does it does riding your bike bother your big toe [doctor] no because i i kinda pedal with the the back of my feet you know on that side [patient] okay do do you wear clips or are you just wearing a regular shoe and on a regular pedal [doctor] i'm on a regular shoe some most of the time i'm in my flip flops [patient] okay okay the how is there anything that you were doing out of the ordinary when this started [doctor] no i do n't that's the thing i do n't remember an injury if it was something that i injured i think i would have just ignored it and would n't have showed up here but when it got red and warm to touch that's when i i was really concerned [patient] okay do does even light pressure to it bother it like at night when you're laying in bed do the sheets bother [doctor] absolutely i was just gon na say when i'm in bed at night and those sheets come down on it or i roll over yeah that hurts a lot [patient] okay have you done anything to try to get it to feel better any soaks or taking any medicine [doctor] i take you know like a two ibuprofen a day and that does n't seem to help [patient] okay [doctor] alrighty [patient] let me see your your foot here and let me take your big toe through a range of motion if i push your top to bottom [doctor] yeah ouch [patient] big toe joint that okay and let me move it up where as i bend it up does that hurt [doctor] it hurts but not as much as when you moved it down [patient] okay so i'm moving it down here and it i've got about ten degrees of plantar flexion does that hurt [doctor] yeah it a little when you take it a little further [patient] if i go a little bit further to twenty degrees does that hurt [doctor] that hurts more yeah [patient] okay if i push in on your big toe and move it back and forth does that hurt [doctor] yes it does and it it's almost like those joints that when you push it back it's almost like it's grinding a little bit too [patient] okay if i push in between your big toe and your second toe here does that hurt [doctor] a little bit but not terrible [patient] okay what about if i push on the other side here [doctor] yeah yeah right there on the outside of it absolutely [patient] okay [doctor] yep [patient] okay and i'm feeling a little bit of bone spur here as well let me let me get an x-ray [doctor] okay [patient] and after we take a peek at that we'll develop a plan [doctor] okay [patient] so at this point what would i do if i'm going out of the room and then coming back [doctor] you could hit pause or hit the stop button and just restart it the next time you come in [patient] okay alrighty so taking a look at your x-ray and you do have you you have a large spur there on the top of your big toe joint [doctor] oh [patient] and you've lost a lot of the cartilage [doctor] oh [patient] and so you you've got some arthritis in there we we call this hallux rigidus and treatment for this to start off with we we put an insert in your shoe called an orthotic and we give you a little bit of anti-inflammatory medication or like a drug called meloxicam you only have to take it once a day [doctor] okay [patient] it's usually pretty well tolerated have you ever had any trouble with your stomach [doctor] no never never had any problems with my stomach i love the i love the mexican's food the hotter the better so i hope i never get a problem with my stomach [patient] i hope you do n't either one of the things that we get concerned about with an anti-inflammatory like that is that it can irritate the stomach so if you do start to notice that you're getting heartburn or pain right there [doctor] yeah [patient] below your your sternum you would need to stop taking the medicine and give me a call [doctor] okay [patient] okay [doctor] okay [patient] and i wan na see you back in two weeks to see how you're doing with that if you're not seeing significant improvement then we may have to talk about doing things that are a little more invasive like doing a shot [doctor] okay [patient] or even surgery to clean out the joint sometimes [doctor] is that surgery [patient] i have to [doctor] would that be [patient] i'm sorry [doctor] would that be surgery clean out the joint [patient] yeah that would [doctor] okay [patient] that would be surgery if if we went in and cleaned out the joint sometimes in really severe cases we even just have to fuse the big toe joint we put it in a position of optimal function and we fuse it there and then your pain goes away you lose some motion but you've already lost quite a bit of motion and and the pain goes away so that that surgery really is very effective but let's try to run from my knife a little bit longer [doctor] okay well you know i do n't think i'm gon na be able to do my work job i'm on my feet every day and i it's and and quite frankly it's fishing season so do you think you can give me a couple weeks off so i can get out and get some fishing done [patient] no i want you to be doing your regular activities i want to know how this because if i put you out of work can you come back in and say it feels better well is was it because of the treatment or because of the rest so no i want you to keep working i want you to do your regular activities and i really want you to put these orthotics to the test and this medicine to the test and we will see how you're doing in two weeks [doctor] okay where i really like catching blue going croppy so okay we'll we'll i'll i'll keep working then i'll find time to do that later [patient] very good we will see you in two weeks [doctor] okay thank you

CHIEF COMPLAINT Right great toe pain. HISTORY OF PRESENT ILLNESS Joseph Walker is a pleasant 58-year-old male who presents to the clinic today for the evaluation of right great toe pain. The onset of his pain began 2 weeks ago, however it worsened last week. He noticed the pain worsening when he was at a trade show convention and he could not ambulate as he was forced to stand there as the pain was there the whole time. He denies any specific injury. The patient describes his pain usually as throbbing and burning, but notes it occasionally changes to sharp, stabbing pain especially with movement or prolonged ambulation. His symptoms also include redness to the right great toe. The patient states that he has been ambulating on his heel to keep his toe from bending. He reports that his pain is present even with the slightest of pressure, which he notes is worse at night when his sheet is touching his right toe. He adds that he has been taking 2 ibuprofen per day, which does not provide him with relief. SOCIAL HISTORY Patient reports that he likes to bicycle ride. REVIEW OF SYSTEMS Musculoskeletal: Reports right great toe pain. Skin: Reports redness. PHYSICAL EXAM MSK: Examination of the right great toe reveals 10 degrees of plantar flexion with pain. Pain to palpation of the right great toe, between the big toe and 2nd toe. Palpated a bone spur on the right great toe. RESULTS X-ray of the right great toe taken today in office reveals a large bone spur on the anterior aspect of the right great toe joint. There is a loss of cartilage with some arthritis present. ASSESSMENT Right foot hallux rigidus. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays revealed hallux rigidus. We discussed treatment options for this and I have recommended that we begin with conservative treatment in the form of custom orthotics. I have also prescribed the patient meloxicam once a day to treat the pain. The patient was instructed to discontinue use and contact the office if gastrointestinal issues develop. I advised the patient that I want him to continue his regular activities. INSTRUCTIONS The patient will follow up with me in 2 weeks to check on his progress. If his pain does not improve with the orthotics, I will recommend a cortisone injection or surgical intervention.

aci

D2N058

[doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced ejection fraction ejection fraction thirty five percent and moderate mitral regurgitation alright russell hi how are you doing today [patient] hey document i i do n't know i'm doing alright i guess [doctor] just alright how's it [patient] well [doctor] how's it been since you've had your heart attack have you been have you been doing alright [patient] no i've been seeing you for years since i had my last heart attack in two thousand eighteen but i've been doing pretty good i ca n't believe this happened again i mean i'm doing okay i guess i just feel tired every now and then and but overall i mean i guess i feel pretty well [doctor] okay good were you able to enjoy the spring weather [patient] yeah some i mean i'm hoping now that i've had my little procedure that i'll feel better and feel like getting back out and and maybe doing some walking there is some new trails here behind the rex center and maybe get out and walk those trails [doctor] that will be fine i know you love walking the trails i know you like looking at the flowers because i think you you plant a lot of flowers as well do n't you especially around this time [patient] yeah i do some gardening around the house [doctor] yeah [patient] and you know i really like photography too being able to go out and take nature pictures [doctor] yeah [patient] so i'm hoping to be able to go out and do that [doctor] okay well we'll we'll do what we can here to get you out and going doing all those fun activities again now tell me have you had any chest pain or any shortness of breath [patient] no not really no chest pain or shortness of breath i've been doing some short walks right around the house so like around the block [doctor] okay [patient] but i stay pretty close to the house i've been doing some light housekeeping and i do n't know i seem to be doing okay i think [doctor] okay alright now tell me are you able to lay flat at night when you sleep or [patient] well i mean i i never have truly laid flat on my back i've always slept with two pillows which is normal for me [doctor] okay [patient] so i mean i guess i really do n't have any troubles with my sleeping [doctor] okay good how about are your legs swelling up [patient] nope i've always i always had skinny ankles like like i got dawn knots legs [doctor] well that's cute were you able to afford your medications and are you taking them as prescribed [patient] yeah i've been taking my medicine i got pretty good insurance there through the plant and and so the co-pay is n't too bad [doctor] okay [patient] and i've been taking them because i do n't want my sense to close up and they told me that that to take them this you know all the time and and i've been taking them since i got out of the hospital [doctor] okay well very good i'm glad you're doing that good for you russell and and then please keep that up now tell me are you watching your salt intake and trying to change your diet [patient] yeah so when i was in the hospital they said something about my way my heart pumps now [doctor] mm-hmm [patient] it it's it's a little low and i might keep fluid on my legs if i'm not careful [doctor] right [patient] and it's gon na be hard because you know i i really do like pizza and and they told me that i'm really gon na have to watch salt and they said that there is a lot of salt and pizza [doctor] there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay [patient] well [doctor] alright so why do n't we go ahead and do a quick physical exam on you here i just want to take a look at you your vital signs look good i'm glad to see you're tolerating the medication well i'm gon na go ahead and feel your neck here i do n't appreciate any jugular venous distention and there are no carotid bruits on your heart exam there is a three out of six six systolic ejection murmur it's heard at the left base but that's pretty much the same as last year so we'll continue to monitor that okay let me listen to your lungs here real quick russell your lungs are clear so good good and your extremities i do n't see any swelling or edema on your right radial artery the cath site there is clean and it's dry and intact and i do n't see any hematoma so that's good and there is a palpable rra pulse so russell i did review the results of your ekg which showed normal sinus rhythm good r wave progression and evolutionary changes which are anticipated so let's go ahead and talk about my assessment plan for you for your first diagnosis of coronary artery disease we are gon na have you continue your your aspirin eighty one milligrams daily and brilinta ninety milligrams twice daily and we're gon na have you continue on that high dose statin that atorvastatin you might call it lipitor eighty milligrams daily and then also continue on that toprol fifty milligrams daily okay and i'm also going to refer you to cardiac rehab so for you to get some education about your heart and also give you the confidence to get back exercising regularly now i know patients love the cardiac rehab program i think you will do well does that sound good to you [patient] that sounds good document [doctor] alright so for your second diagnosis here the newly reduced left ventricular dysfunction and moderate mitral regurgitation i think your pumping function will improve in time you know they got you to the lab quickly so i think that heart muscle is just stunned and you're very compliant you're very good with your medications and following through with those so i think it will recover so that said i want you to go ahead and continue continue your lisinopril twenty milligrams a day i do n't think you need a diuretic at this time but i do want to add aldactone twelve . five milligrams daily and then you'll need to get labs next week okay and then we're gon na repeat another echocardiogram echocardiocardiogram in about two months [patient] okay [doctor] okay and then for your hypertension your third diagnosis of hypertension i want your to take your blood pressure just like you would you know every so often and then because your blood pressures actually seem fine at this time so we will continue to monitor that and i think you will tolerate the aldactone well as well [patient] alright sounds good document [doctor] okay well you take care and you have a good evening [patient] yeah you too [doctor] bye

CHIEF COMPLAINT Hospital follow-up after an anterior STEMI. MEDICAL HISTORY Patient reports history of CAD status post prior RCA stent in 2018, hypertension, and diabetes mellitus. SURGICAL HISTORY Patient reports history of RCA stent in 2018 and most recently underwent drug-eluting stent placement in the LAD. SOCIAL HISTORY Patient reports enjoying walking outside, gardening, and nature photography. MEDICATIONS Patient reports taking aspirin 81 mg daily, Brilinta 90 mg twice a day, Lipitor 80 mg daily, Toprol 50 mg daily, and lisinopril 20 mg a day. REVIEW OF SYSTEMS Constitutional: Reports fatigue. Denies changes in sleep. Cardiovascular: Denies chest pain. Respiratory: Denies shortness of breath. Musculoskeletal: Denies lower extremity swelling. VITALS Vital signs look good today. PHYSICAL EXAM Neck - General Examination: No carotid bruits. Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular - Auscultation of Heart: Grade 3/6 systolic ejection murmur, heard at the left base. Musculoskeletal - Examination of the right upper extremity reveals no swelling or edema on the right radial artery. Cath site is clean, dry, and intact. No hematoma. Palpable right radial artery pulse. RESULTS Electrocardiogram is reviewed and revealed normal sinus rhythm with good R wave progression and evolutionary changes, which are anticipated. ASSESSMENT AND PLAN 1. Coronary artery disease. - Medical Reasoning: The patient's exam is consistent with coronary artery disease. - Patient Education and Counseling: We discussed that he should continue to watch his diet and salt intake. We also discussed that the cardiac rehab should help with his confidence with exercising regularly and for his education. - Medical Treatment: Continue taking aspirin 81 mg daily Continue taking Brilinta 90 mg twice a day. Continue taking Lipitor 80 mg daily. Continue taking Toprol 50 mg daily. I will refer him to cardiac rehab. 2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation. - Medical Reasoning: The patient's physical exam is consistent with this diagnosis. - Patient Education and Counseling: We discussed that his pumping function should improve in time. We also discussed that since he is compliant with his medications and presented to the cardiac cath lab quickly, he should recover. I advised the patient that he does not need to start a diuretic at this time. - Medical Treatment: Continue taking lisinopril 20 mg a day. Prescription for Aldactone 12.5 mg daily provided. Order for labs provided. Repeat echocardiogram ordered to be completed in 2 months. 3. Hypertension. - Medical Reasoning: This seems stable at this time. - Medical Treatment: Continue home blood pressure monitoring. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

aci

D2N059

[doctor] okay [patient] good morning [doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it [patient] sure absolutely what can i help you with today [doctor] so you know i've been dealing with my asthma and like i tried to join sports but it's really kind of it's getting hard you know and i i i just wonder if there's something that can be done because i really do like playing water polo [patient] but i'm having difficulty breathing sometimes i've had to like you know stop matches and sit on the side just to kind of like catch my breath and use my inhaler so i was wondering if there was something we could do about it [doctor] and then like i'm kind of a little bit worried i think my mood is getting a little a little worrisome and i i wanted to explore like what my options were [patient] okay let's talk about the asthma first so what inhaler are you using now [doctor] i have an albuterol inhaler [patient] okay and when when you're having trouble it's usually just around sports that is it keeping you up at night [doctor] so i do n't really like wake up at night a lot typically like it's sports like you know if i'm doing anything like crazy aerobic or like running or anything i do notice that if any if i'm around smoke i do start coughing a little bit but most of the time it's sports [patient] okay and can you describe a little bit for me what happens [doctor] i start to yeah no so i start to feel like there is like some phlegm building up in my in my throat and i start coughing like my chest gets tight i start wheezing and i just have to sit down or else i'm gon na get like lightheaded too [patient] okay and then when you use your inhaler [doctor] mm-hmm [patient] does it does it alleviate the problem [doctor] so yeah it helps with that like phlegm feeling you know but i still i still have to sit down you know and like breathe and then the thing that i hate about that inhaler is i start getting like shaky is that supposed to be happening [patient] yes that is unfortunately normal and a side effect with the inhaler [doctor] okay [patient] so you use you're using two puffs of the inhaler [doctor] mm-hmm [patient] for the symptoms [doctor] yes [patient] and then you sit down and does it does it get better within about fifteen minutes or so [doctor] yeah yeah it does but you know i had to like step out of the the pool to make that happen i'm hoping that there is something else we can do okay have you ever taken any daily medications for your asthma an inhaler or singulair or anything like that no i i just use my inhaler whenever i have an attack [patient] okay so that's something we might wan na consider but how often is it happening [doctor] pretty much every time i do any kind of aerobic workout [patient] okay and outside of physical activity you're not having any problems [doctor] yeah there's that part where like if i'm around somebody who has been smoking a lot or is currently smoking but i usually just step away i do n't even like to be around them you know that makes sense [patient] alright well we will look at that tell me about the mood issues you are having [doctor] yeah so one of the reasons i got into like trying to get into sports is like i feel like you know you you feel a lot more energized and a lot you know happier but like lately i've just been kinda stressed out you know like i have i have like sats that i need to study for i've got like all these ap classes you know there's just it i feel like there's a lot of pressure and you know like i get it but there are times where i'm just like really down and i i do n't really know what else i can do [patient] okay that makes sense any any difficulty with focusing or you're having difficulty retaining information or is it more feeling sad not having motivation [doctor] so i think it's like a lot of sadness a lot of like you know i do n't really i kinda feel like you know i do n't really like want to do anything you know my friends will go out and i'll just be like i'd rather be at home i am really tired a lot too [patient] okay alright well let me let me go ahead and check you out [doctor] mm-hmm [patient] and then we can talk a little bit more [doctor] okay [patient] i'm gon na take a listen to your heart and lungs [doctor] mm-hmm [patient] and everything sounds good [doctor] let me take a look at your eyes [patient] mm-hmm and in your ears everything looks okay have you had any problems with allergies you have seasonal allergies or anything like that [doctor] yeah i think so yeah [patient] i do see just a little bit of fluid in the ears [doctor] mm-hmm [patient] and i'm gon na look in your mouth too [doctor] okay [patient] and throat looks fine no tonsils [doctor] mm-hmm [patient] lem me go ahead and have you lay back on the table and i'll take a listen to your stomach [doctor] okay [patient] everything sounds okay i'm gon na feel around just to make sure everything feels normal [doctor] mm-hmm [patient] everything feels fine and i'm gon na check reflexes and they're all normal [doctor] awesome [patient] it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair [doctor] mm-hmm [patient] and start with that once you are on that daily and you can continue to use the albuterol inhaler those side effects unfortunately you're right it's it's just one of the expected side effects with an albuterol inhaler i would recommend just what you're doing just sit down for a little bit after you take it [doctor] and we will get you started on the singulair probably within about a month you should see a difference so i will have you come back in about six weeks and follow up and see how you're doing with that [patient] in terms of the mood is this new for you [doctor] yeah i think so like when i started this year [patient] and it sounds like related to school expectations and the stress with saps and all of that [doctor] yeah [patient] okay let's consider having you start seeing a therapist i think that would be a good place to start [doctor] mm-hmm [patient] and we will do some screening questionnaires and and then follow up in a couple weeks on that too [doctor] okay alright sounds like a plan okay [patient] thank you

CHIEF COMPLAINT Asthma. MEDICAL HISTORY Patient reports history of asthma. SURGICAL HISTORY Patient reports history of tonsillectomy. SOCIAL HISTORY Patient reports she is a student and enjoys playing water polo as well as being active with aerobics and running. ALLERGIES Patient reports history of seasonal allergies. MEDICATIONS Patient reports using an albuterol inhaler, 2 puffs as needed. REVIEW OF SYSTEMS Constitutional: Reports fatigue. Respiratory: Reports shortness of breath. Psychiatric: Reports mood changes. PHYSICAL EXAM Ears, Nose, Mouth, and Throat - Examination of Ears: Mild fluid in ears. - Examination of Mouth: Normal. - Examination of Throat: Tonsils have been previously removed. Gastrointestinal - Auscultation: Bowel sounds normal in all 4 quadrants. Integumentary - Examination: No rash or lesions. Normal capillary refill and perfusion. - Palpation: No enlarged lymph nodes. ASSESSMENT AND PLAN 1. Asthma. - Medical Reasoning: The patient has experienced an increased need to use her albuterol inhaler. She is not currently utilizing a daily medication. At this time, we will try a daily medication since it looks like she might be having some allergies. - Patient Education and Counseling: I explained the side effects of albuterol to the patient. We also discussed Singulair and that she should start to see a difference in her breathing within approximately 1 month. - Medical Treatment: We will start her on a daily asthma medication. She can continue to use the albuterol inhaler. We will start her on Singulair in about a month. 2. Mood. - Medical Reasoning: The patient reports being under a lot of stress with school. I believe this may be attributing to her mood. - Medical Treatment: I would like for the patient to be seen by a therapist. She will also complete our screening questionnaire. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 6 weeks for recheck.

aci

D2N060

[doctor] hey jean how're you doing today [patient] i'm doing alright aside from this foot pain that i have [doctor] so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened [patient] yeah so yeah i was playing in a soccer game yesterday and i was trying to steal the ball from another player and she ended up falling directly onto my right foot and i do n't know i i mean i was trying to get around her and my body ended up twisting around her and then i accidentally felt a pain in my foot [doctor] okay so have you ever hurt your left foot before [patient] no i've had a lot of injuries in soccer but never injured this foot [doctor] okay and then so after the fall and the entanglement with the other player were you able to continue playing [patient] no i had to stop playing right away and actually being helped off the field [doctor] wow okay and what have you been doing for the the pain since then [patient] so i've been keeping it elevated icing it the trainer wrapped it yesterday and taking ibuprofen as well [doctor] okay alright so without any ibuprofen can you tell me what your pain level is [patient] without ibuprofen i would say my pain is a three [doctor] okay and then with your ibuprofen can you tell me what your pain level is [patient] like a seven eight [doctor] okay so how long have you been playing soccer [patient] really since i was like four five i've been playing a long time [doctor] well that's cool yeah we our our youngest daughter she is almost sixteen and she plays the inner marrial soccer league they are down at the rex center did is that where you started playing or did you guys did you start playing somewhere else [patient] yeah just like this local town leak i started playing that way and then played all throughout school [doctor] that's [patient] high school teams [doctor] that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation [patient] no i have not [doctor] okay now if it's okay with you i would like to do a quick physical exam i reviewed your vitals and everything looks good blood pressure was one eighteen over seventy two heart rate was fifty eight respiratory rate was fourteen you are afebrile and you had an o2 saturation of ninety nine percent on room air on your heart exam your regular of rate and rhythm do n't appreciate any clicks rubs or murmurs no ectopic beats noted there on auscultation listening to your lungs lungs are clear and equal bilaterally so you're moving good air i'd like to do a focused foot exam on your left foot so i do see some bruising on the bottom of your foot and on the top of your foot as well now there is associated swelling and i do appreciate tenderness to palpation of your midfoot and you are positive for the piano key test on a neurovascular exam of your left foot you have a brisk capillary refill of less than three seconds dorsalis pedis pulse is intact and strong and you do have motor and sensation that it's intact to light touch now i would like to do a review of the diagnostic imaging that you had before you came in so i do notice a subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space so lem me talk to you a little bit about my assessment and plan now for for the first concern of right foot pain your right foot pain is due to a lisfranc fracture which is a fracture to one of your second metatarsal bones at the top of your foot where the metatarsals meet your cuboids now there are ligaments at the top of your foot so i'm gon na be ordering an mri to assess for injury to any of these ligaments now based on your exam and from what i'm seeing on your x-ray you're most likely going to need surgery of that foot now the surgery will place the bones back in their proper position and using plates and screws will hold them there while they heal and this is gon na allow those bones and ligaments to heal properly it is a day surgery and you will be able to go home the same day and then i'm going to have you follow up with me here in the clinic you'll be in a cast and you will need to use crutches and you will not be able to use that left foot for about six to eight weeks now after that six to eight weeks you will gradually start walking on your foot based on how you tolerate it and we'll see how you do at that point so i do believe you're gon na need surgery i i'm recommending this because there are significant complications to your foot if we do not do this poor bone and ligament healing can lead to losing the arch of your foot and you're becoming flat-footed you also have a high likelihood of developing arthritis in that foot so what i'm gon na do unfortunately you'll be out the rest of the season but we are gon na get you fixed up and ready for next season if you're okay with all of this i'm gon na have the nurse come in and get you started on your paperwork and then i will see you on monday morning and we will get your foot taken care of [patient] alright thank you [doctor] you're welcome

CHIEF COMPLAINT Left foot pain. HISTORY OF PRESENT ILLNESS Jean Martinez is a pleasant 27-year-old female who presents to the clinic today for the evaluation of left foot pain. The patient sustained an injury to her left foot while playing soccer yesterday. She became entangled with another player, causing the player to fall onto the patient's foot, resulting in immediate pain. After the incident, she required help to get off of the field and was unable to participate for the rest of the game. Her trainer wrapped her foot, and she has tried ice, elevation, and ibuprofen to treat her symptoms. with medication, she rates her pain as 3/10, but without medication her pain is rated as 7-8/10. There is no numbness, tingling, or other abnormal sensations associated with her pain. Of note, the patient has sustained several injuries in the past while playing soccer, but this is her first left foot injury. MEDICAL HISTORY The patient reports that she has sustained several soccer injuries in the past. SOCIAL HISTORY The patient has been playing soccer since she was 4 or 5 years old. She is currently playing in a local league. MEDICATIONS The patient reports that she has been taking ibuprofen. REVIEW OF SYSTEMS Musculoskeletal: Reports left foot pain. Neurological: Denies left foot numbness or tingling. VITALS Blood pressure: 118/72 mmHg Heart rate: 58 bpm Respiratory rate: 14 Temperature: Afebrile Oxygen saturation: 99% on room air PHYSICAL EXAM CV: Regular rate and rhythm without clicks, rubs, or murmurs. No ectopic beats noted on auscultation of the heart. Brisk capillary refill, less than 3 seconds. Dorsalis pedis pulse is intact and strong. RESPIRATORY: Lungs are clear and equal bilaterally. NEURO: Motor and sensation in the left foot are intact to light touch. MSK: Examination of the left foot: Ecchymosis on the plantar and dorsal aspects of the foot. Associated swelling. Tenderness to palpation of the midfoot. Positive piano key test. RESULTS X-ray images of the left foot were obtained and reviewed today. These reveal subtle dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases. There is presence of a bony fragment in the Lisfranc joint space. ASSESSMENT Lisfranc fracture, left foot. PLAN I explained the nature of her injury in detail. Based on her exam and x-ray findings, she will most likely require surgery of the left foot, but I want to order an MRI to assess for any ligamentous injuries. We discussed the procedure and postoperative expectations, such as recovery time and restrictions, at length. We also discussed the complications associated with deferring surgical intervention including poor bone and ligament healing, pes planus deformation, and a high likelihood of developing arthritis in the foot. She will be unable to participate for the remainder of the soccer season, but should be able to play next season. INSTRUCTIONS We will see the patient on Monday, for surgery.

aci

D2N061

[doctor] hi virginia how're you today [patient] i'm good thanks how are you [doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened [patient] i was playing basketball and jerry ran into me and the inside of my knee hurts [doctor] okay did you fall to the ground or did you just kinda plant and he pushed and you went one way and your knee did n't [patient] i did fall to the ground [doctor] you did fall to the ground okay and did you land on the kneecap i mean did it hurt a lot were you able to get up and continue on [patient] i landed on my side i was not able to continue on [doctor] okay so you get off the off the court is jerry a good player you just got ta ask that question [patient] not really [doctor] no [patient] he does n't have much game [doctor] okay okay well you know i love basketball i'm a little short for the game but i absolutely love to watch basketball so it's really cool that you're out there playing it so tell me about a little bit about where it hurts [patient] on the inside [doctor] on the inside of it okay and after the injury did they do anything special for you or you know did you get ice on it right away or try anything [patient] i had ice and an ace wrap [doctor] you had ice and what [patient] an ace wrap [doctor] and an ace wrap okay now how many days ago was this exactly [patient] seven [doctor] seven days ago okay yeah your right knee still looks a little swollen for seven days ago so i'm gon na go ahead and now i also see that you're diabetic and that you take five hundred milligrams of metformin twice a day are you still you're still on that medication is that correct [patient] correct [doctor] and do you check your blood sugars every morning at home [patient] every morning [doctor] okay great and since this i'm the reason i'm asking all these questions i'm a little concerned about the inactivity with your your knee pain and you know how diabetes you need to be very you know active and and taking your medicine to keep that under control so you know may wan na continue to follow up with your pcp for that diabetes as we go through here and just watch your blood sugars extra as we go through that now i'm gon na go ahead and examine your your right knee and when i push on the outside does that hurt at all [patient] no [doctor] okay and when i push on this inside where it's a little swollen does that hurt [patient] yes [doctor] yeah okay i'm just gon na ask a question did you hear or feel a pop in your knee when you were doing this [patient] i did not no [doctor] you did not okay okay what are you doing for the pain today [patient] some exercises ice and mobic [doctor] okay okay so i'm gon na continue all of my exam when i go ahead and pull on your knee the first thing i'm looking at is i do see some ecchymosis and swelling on the inside of that right knee and when i push around that knee i can see that there is fluid in the knee a little bit of fluid in the knee we call that effusion so i can appreciate some of that effusion and that could be either fluid or blood at this point from the injury that you had now you do have pain with palpation on the medial aspect of that right knee and that's that's concerning for me when i'm gon na just i just wan na move your knee a little bit it does n't look like when i extend it and flex it that you have a full range of motion does it hurt a lot when i moved it back a little more than normal [patient] yes it hurts [doctor] okay okay yeah so you do have some decreased range of motion in that right knee now i'm just gon na sit here and and lay you back and i'm gon na pull on your knee and twist your knee a little bit okay you currently there is a negative varus and valgus stress test that's really important so here's what i'm thinking for that right knee i think you have may have a medial collateral ligament strain from you know maybe the twisting motion be right before you fell to the ground i want you to continue to use an ace wrap i'm gon na give you a right knee brace we're gon na wear that for a few days and then i'm gon na send you to physical therapy so we can continue strengthening the muscles around the right knee now that x-ray as far as the x-ray results that x-ray that i did it this morning in the office the the bony alignment's in good position i do n't see any evidence of any fractures i do notice the the effusion around the right knee just a small amount of fluid but we're just gon na continue to watch that i'm gon na give you a prescription i'd like you to stop taking any of the nonsteroidals that you're taking the motrin or advil whichever one of those and i'm gon na give you meloxicam fifteen milligrams and i want you to take that daily for the pain and swelling i want you to just continue exercising with the the braces and everything on so if you can you can get out and do some light walking that'll be good and then again for your diabetes like i said just continue to watch those blood sugars daily and if you start to see any significant increase in them because of your loss of activity just reach out to your primary care physician now do you have any questions for me [patient] when can i play basketball again [doctor] yeah that's a great question i'm gon na ask well my first off i want to see you back here in in seven days you know in a week i want you to make an appointment we're gon na relook at it we're gon na determine if that swelling got any worse and if we need to go on to potentially ordering like a cat scan or an mri of that knee to look and see if there was any significant damage to the ligament so that's for for sure for seven days you're not gon na be playing basketball now are you in a ligue or is that just you get like pick up basketball [patient] i just played the wife with fun [doctor] okay okay good that's a great activity like i said i wish i could play now i i also know your your family do n't they own that sports store down right off a main street that sells a lot of sporting equipment [patient] yeah they do [doctor] okay i you know i'm i'm just thinking you know i need to get some new shoes for some of it my activities i love the i wish i could play basketball but i do a lot of bike riding so i'm always looking for anything that's gon na help me on the bike do you does your family have supplies like that [patient] we do let me know and i can get you the hook up [doctor] okay great great so i'll i i will let you know i'll just get on and take a look first but i'm gon na go ahead and get get you discharged i'll have my assistant come in we will get you discharged and like i said we will make an appointment for seven days and we will go from there any questions [patient] i think you've answered them all thank you [doctor] okay great

CHIEF COMPLAINT Right knee pain. HISTORY OF PRESENT ILLNESS Virginia Phillips is a pleasant 53-year-old female who presents to the clinic today for the evaluation of right knee pain. The onset of her pain began 7 days ago, when she was playing basketball and another player ran into her. She states that she fell to the ground and landed on her side. She denies hearing or feeling a pop at the time of the injury. The patient localizes her pain to the medial aspect of her knee. She used ice and an ACE wrap right after the injury. Today, she notes that she has been doing exercises, ice, and Mobic for pain control. MEDICAL HISTORY The patient reports she is a diabetic who takes her blood sugar every morning. SOCIAL HISTORY Patient reports that she plays basketball at the Y for fun. MEDICATIONS Patient reports that she takes metformin 500 mg twice a day. REVIEW OF SYSTEMS Musculoskeletal: Reports right knee pain. PHYSICAL EXAM MSK: Examination of the right knee: No pain to palpation of the lateral aspect of the right knee. Pain with palpation on the medial aspect of the knee. Ecchymosis and swelling on the medial aspect of the knee. Effusion is appreciated. Decreased ROM. Negative varus and valgus stress test. RESULTS X-rays of the right knee taken in office today reveal the bony alignment in good position. There is no evidence of any fractures. There is effusion present. ASSESSMENT Right knee pain, possible medial collateral ligament strain. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have prescribed the patient meloxicam 15 mg once a day to treat the pain and swelling. She was advised to stop taking any anti-inflammatory such as Motrin or Advil. I have also recommended that the patient attend formal physical therapy to strengthen her right knee. I have also advised her to continue to use the ACE wrap and wear a right knee brace for a few days. She should continue light walking with her brace on. The patient was advised to stop basketball until she follows up in 7 days. Regarding her diabetes, she should continue to monitor her blood sugars daily. She should reach out to her primary care physician if she sees an increase in her blood sugars due to loss of activity. INSTRUCTIONS The patient will follow up with me in 7 days to check on her progress. If her swelling has not improved, we will consider obtaining a CT or MRI of the right knee to evaluate for a possible medial collateral ligament strain.

aci

D2N062

[doctor] okay raymond it looks like you've been having some difficulty swallowing over for a period of time could you tell me like what's going on [patient] well i've been better for the last several weeks i've been noticing that it's been hard for me to swallow certain foods and i also have pain when i swallow down in my chest [doctor] okay and when does it does it happen every time you eat [patient] it hurts not every time it hurts when i when i swallow most foods but it's really just the bigger pieces of food that seem like they're getting stuck [doctor] okay and what do you mean by bigger pieces of food like what's your diet like [patient] well things have been stressed over the last couple of months so lacks a moving from the west coast of east coast so i've been drinking more eating things like pizza burgers i know it's not good but you know it's been pretty busy [doctor] wow that sounds kinda stressful like what are you moving for [patient] well i'm stressed because what i'm moving because you know i i do n't like the west goes so i i decided to move but you know it's just stressful [doctor] uh uh [patient] because i do n't know how my dog is gon na handle the travel but i do n't wan na put them into the carbo portion of the plane we fly out of her really bad stories of dogs got in the wreck [doctor] okay so are you thinking of driving [patient] i i think so i think i'm i think i'm gon na end up driving but that's still a a long trip [doctor] yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms [patient] no i wish unfortunately i've gained some weight [doctor] okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea [patient] sometime my belly hurts up here [doctor] okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool [patient] not that i noticed [doctor] okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt [patient] no i did that hurts [doctor] okay pain to palpation of epigastric area how about now [patient] no [doctor] okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for your i reviewed the results of your barium swallow and it showed that you have two areas of mild narrowing in the mid and lower portions of your esophagus that can be found in patients experiencing something called esophagitis so for your primary primary problem you have acute esophagitis i wan na go ahead and prescribe protonix it's forty milligrams you're gon na take that once a day you should take it the first thing in the morning i also wan na prescribe to you something called carafate you take one gram four times a day for one month that's just gon na help kind of coat your the in the lining of your esophagus and like your stomach so that you're again like not producing a whole lot of acid like your your pretty much your the acid in your stomach is getting where it does n't need to be and it's a bit too strong so we're gon na give your body time to do a reset i wan na schedule you for an upper endoscopy just to be sure we are n't missing anything else i encourage you to change your diet and decrease alcohol and caffeine i know that's gon na be pretty hard with the move but you know once especially once you're settled in it's gon na be very important for us to to like focus on like getting well and eating healthy so that you know like you can you can move about your day as best as you can and and enjoy your move i want you to consider like eating slowly and chewing your food more thoroughly so that you do n't have to deal with those big pieces i also want you to avoid citrus foods fruits and spicy foods until your symptoms have improved i wan na see you again next week for that endoscopy i know there was a lot of information do you have any questions [patient] no i think that's all good [doctor] okay alright thank you so much for coming in

CHIEF COMPLAINT Difficulty swallowing. HISTORY OF PRESENT ILLNESS Raymond Taylor is a pleasant 67-year-old male who presents to the clinic today for difficulty swallowing. The patient notes that the pain has been occurring for the last several weeks. The pain radiates to his chest when he swallows. He notes that he does not have pain every time he eats but mostly when he has big pieces of food as they seem to get stuck. Mr. Taylor notes that it has been stressful for him the past couple of months as they moved from the West Coast to the East Coast, so he has been drinking more, and having pizza, and burgers more. He denies any weight loss, but endorses weight gain. The patient states that he has epigastric pain, but denies dark, tarry stools. REVIEW OF SYSTEMS Constitutional: Reports weight gain. HENT: Reports dysphagia. Gastrointestinal: Reports epigastric pain. Denies dark, tarry stools. Neurological: Positive stress. VITALS BP: 133/70. Heart rate looks good. Temperature is within normal limits. SpO2: 100%. Respiratory rate: 19. PHYSICAL EXAM EYES: Equal and reactive to light. NECK: No adenopathy, thyromegaly. RESPIRATORY: Normal respiratory effort no respiratory distress GI/GU: Non-distended Active bowel sounds. Pain to palpation of epigastric area. Negative McMurphy's Sign. No peritoneal signs. No rebound. SKIN: No rash, no lesion, no bruising. MSK: Examination of the mouth reveals no obvious ulcers or evidence of thrush present. Tonsils are midline of the neck. RESULTS The barium swallow study revealed two areas of mild narrowing in the mid and lower portions of your esophagus. ASSESSMENT Acute esophagitis. PLAN After reviewing the patient's examination and barium swallow findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have prescribed the patient Protonix 40 mg first thing in the morning to treat his acute esophagitis. I have also prescribed the patient Carafate 1 gram 4 times daily for 1 month to help coat the lining of his esophagus and stomach. I recommended a upper endoscopy for further evaluation. I have also advised him to change his diet, decrease alcohol, and caffeine. I have also advised him to avoid citrus foods, fruits, and spicy foods until his symptoms have improved. We discussed that he should eat slowly and chew his food thoroughly to avoid big pieces of food. All questions were answered. INSTRUCTIONS The patient will follow up with me in 1 week for his endoscopy.

aci

D2N063

[doctor] so gloria is a 46 -year-old female today with past medical history of diabetes and back pain and today here for shortness of breath with chf and copd also so gloria tell me what's going on [patient] i i i'm having a lot of trouble sleeping [doctor] okay and and how long has this been going on for [patient] really just for about the past two weeks i i just ca n't ca n't get comfortable you know when i when i lay down in bed i just ca n't ca n't fall [doctor] is it because you're having you ca n't sleep or you're having shortness of breath or difficulty breathing or what's going on with that [patient] yeah i i feel like i'm just i'm just choking a few minutes after i i lay down to sleep i just ca n't catch my breath [doctor] okay and are you and how has your pulse ox been your oxygen level been at home i know you your oxygen level here is like ninety two right now in the office which is a little bit on the low side how is how has that been at home [patient] i can breathe fine [doctor] just when you lay down you get short of breath okay and is it worse when you have you noticed any shortness of breath during the day when you exert yourself when you climb stairs or do other stuff [patient] i do n't i do n't do any of that usually i just i i sit on the couch and watch my shows [doctor] okay fair enough and how about have you noticed any weight gain or swelling in your legs or calves or anything like that [patient] yeah i i ca n't see my ankles anymore and and yeah i i do n't know what's going on with the scale i think the numbers are off because you know suddenly i gained about ten pounds [doctor] wow okay alright and are you taking i know you were supposed to be taking lasix and we had you on you know diet control to to prevent to limit your salt intake how is that going [patient] i i i do n't know how much salt is in freedoes but you know i i i'm really enjoying those in last weekend we got this really big party and yeah which color is that lasix pill [doctor] yeah it's it's the white one the round one so it sounds like you're not maybe not taking it as regularly as you should [patient] no sir i i do n't think i am [doctor] okay alright and are you having any chest pain or tightness in your chest or anything like that or not really [patient] no not really [doctor] okay [patient] just just when i ca n't breathe good at night you know [doctor] okay got it [patient] yeah [doctor] so i'll examine you in a second so it's been a couple of weeks are you coughing up anything any fevers with this at all [patient] no no fever kinda feel like i'm just bringing a whole bunch of yuck up once in a while though especially first thing in the morning [doctor] okay alright and how have your blood sugars been doing this time i know you're taking the metformin are you checking your accu-cheks how has that been going [patient] i i'm sorry what's an accu-chek [doctor] for your blood sugar check are you checking that or not really [patient] i i i did it a couple of weeks ago [doctor] okay [patient] and it was about it i i think about two thirty it was okay [doctor] okay so your hemoglobin a1c last time was seven . five and we had talked about you know trying to improve your diet we had talked about you know we wan na avoid going to insulin but it sounds like it's been a challenge to kinda control the diet and also your blood sugars have been running a little bit high [patient] yeah [doctor] okay alright [patient] yeah it's it's been a challenge [doctor] alright and any nausea vomiting or diarrhea or anything like that are you peeing a whole lot or anything like that no [patient] yeah i'm feeling like crazy [doctor] okay alright [patient] ca n't figure out why because i'm not drinking very much [doctor] alright and how is your back then has that been okay i know you're sitting you said you're sitting on the couch a lot watching tv but [patient] yeah [doctor] besides that anything else [patient] yeah you know it it just it just really hurts so you know and so that's why i sit on the couch so much [doctor] okay alright no weakness or numbness in your legs right now [patient] no [doctor] okay [patient] no [doctor] so let me examine you now gloria i'm gon na go ahead and do an exam and let's pretend i did my exam i'm just gon na verbalize some of my findings just so i can record this and put it into my my into my chart so neck exam you do have a little bit of swelling in your neck little bit of jvd no bruits your lung exam you have some crackles in both bases and some rales that i can hear and there are a little bit of intermittent wheezing as well on your heart exam you have a two over six systolic ejection murmur you've had that in the past otherwise regular rate and rhythm it does n't feel a regular your belly exam your belly's slightly distended there's no tenderness or guarding or anything like that so that does n't that looks pretty good on your leg exam you do have some one plus pitting edema or actually almost one and a half plus pitting edema in your both of your ankles no calf tenderness negative homans sign that means no blood clots otherwise neurologic exam is normal the rest of your exam is normal so what does this all mean so let me explain that so for the first problem the shortness of breath you know i think you have an exacerbation of your congestive heart failure what i'd like to do is increase your dose of lasix from twenty milligrams to sixty milligrams for the next four days i'm gon na have you check your weights everyday and also i'm gon na go ahead and have you use your albuterol and atrovent we had given you some inhalers in the past i can give you another refill if you need to help with that some of the breathing that you're having the shortness of breath so i'd like to get some of this fluid off you have you check your weights daily we'll have you increase your dose of lasix we'll have you use a breathing treatments and see if that helps your shortness of breath i'd like to have you come back in about couple days actually i wan na see how you're doing and if it does n't get better we may have to increase the dose or send you to the hospital okay [patient] i do n't want to go to the hospital doctor [doctor] yeah so let's try to let's try to use the lasix and let's try to let's try to you know use the breathing treatments and and do that for the second problem the diabetes that we just talked about i like to go ahead and order another blood test another hemoglobin a1c i think we need to your blood sugars have been running a little bit high in the past and we've had a hard time but it's been a while since we checked your last one so i wan na check another one today to see where we are and when we have you come back in a couple days we should have the results back we can then adjust your metformin or we may have to adjust some of the you know add a different medication at that point but but right now i'm gon na order some blood tests we'll have you come back in a couple of days and then we can reassess at that point okay [patient] so i had a piece of cake before i came in here is that gon na affect the the lab work [doctor] yeah we'll probably do a fasting blood sugar we'll we'll order the hemoglobin a1c that should n't be actually matter because that checks long term but if we need your blood sugar may be elevated today i i would n't be surprised alright and i forgot to examine your back by the way so on your back exam you do have some tenderness in the paraspinal areas of your back in the in the lower back mostly no midline tenderness you have good reflexes so i think this is all muscular pain right now for your back pain i'm gon na go ahead and put you on some naprosyn and some flexeril which is a muscle relaxer i'm gon na give you some exercises you can do to help you get off the couch it'll also help your blood sugar and why do n't we have you if that does n't work the the pain medicine and the physical we can start physical therapy and see if that helps okay [patient] okay [doctor] any questions about that [patient] i do n't think so which color pills [doctor] i think it's a white pill and it's round [patient] okay [doctor] about this big [patient] alright sounds good [doctor] anything else gloria [patient] no that's it [doctor] alright thanks for coming in today

CHIEF COMPLAINT Dyspnea. MEDICAL HISTORY Patient reports history of diabetes, back pain, congestive heart failure, and chronic obstructive pulmonary disease. SOCIAL HISTORY Patient reports living a sedentary lifestyle. MEDICATIONS Patient reports she is not consistent with taking Lasix and metformin. REVIEW OF SYSTEMS Constitutional: Reports 10 pound weight gain. Denies fever. Cardiovascular: Denies chest pain or tightness. Respiratory: Reports orthopnea and productive cough. Denies dyspnea on exertion. Gastrointestinal: Denies nausea, vomiting, or diarrhea. Genitourinary: Reports polyuria. Musculoskeletal: Reports back pain and lower extremity edema. Neurological: Denies lower extremity weakness or numbness. VITALS Oxygen saturation: 92% PHYSICAL EXAM Neck - General Examination: Slight swelling. Mild JVD. No bruits. Respiratory - Auscultation of Lungs: Mild rales heard at the base bilaterally and slight intermittent wheezing. Cardiovascular - Auscultation of Heart: 2 out of 6 systolic ejection murmur, otherwise regular rate and rhythm. Gastrointestinal - Examination of Abdomen: Slightly distended. No tenderness or guarding. Musculoskeletal - Examination: 1.5+ pitting edema in the ankles bilaterally. No calf tenderness. Negative Homan's sign. Slight tenderness in the paraspinal area, mostly in the lower back. No midline tenderness. Good reflexes. RESULTS Hemoglobin A1c: 7.5 ASSESSMENT AND PLAN 1. Shortness of breath. - Medical Reasoning: I believe this is an exacerbation of her congestive heart failure. - Patient Education and Counseling: I advised the patient to monitor her weight daily. - Medical Treatment: She will increase her dose of Lasix from 20 mg to 60 mg for the next 4 days. She should also use her albuterol and Atrovent inhalers as needed. If her symptoms don't improve in the next couple of days, we will either increase her doses or have her go to the hospital. 2. Diabetes type 2. - Medical Reasoning: Her recent blood glucose levels have been elevated. - Patient Education and Counseling: We discussed the possibility of needing to add another medication to her regimen. - Medical Treatment: We are going to order a repeat hemoglobin A1c and adjust her dose of metformin accordingly. 3. Back pain. - Medical Reasoning: This appears to be all muscular pain. - Patient Education and Counseling: We discussed exercises she can do to help her pain and that ff this doesn't help we can consider physical therapy. - Medical Treatment: Prescriptions provided for Naprosyn and Flexeril. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS We will have her follow up in a couple of days.

aci

D2N064

[doctor] hey matthew how're you doing [patient] hey doc i'm doing pretty good how are you [doctor] i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that [patient] yeah i did my wife and i were on a walk yesterday and i was just talking to her and and stepped off the curb and landed on it wrong it's kind of embarrassing but yeah it's been killing me for a couple days now [doctor] okay now when you fell did you feel or hear a pop or anything like that [patient] i would n't say i really heard a pop it was just kind of really kind of felt extended and stretched and it it's just been really bothering me ever since kind of on the outside of it [doctor] okay and then were you able to walk on it after the incident [patient] i was able to get back to the house because i did n't wan na you know make my wife carry me but it was it was painful [doctor] okay and then have you done any or had any injuries to that ankle before [patient] nothing substantial that i would say in the past [doctor] okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less [patient] i have taken some ibuprofen and then i just tried to elevate it and ice it a little bit and keep my weight off of it [doctor] okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me [patient] i would say it's about an eight [doctor] okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then [patient] maybe a seven it it's a little [doctor] okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there [patient] we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time [doctor] yeah i [patient] no i have n't been there yet [doctor] yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay [patient] awesome [doctor] so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up [patient] no i think that sounds like a plan [doctor] okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks [patient] awesome thanks document [doctor] alright thanks bye-bye

CHIEF COMPLAINT Left ankle pain. HISTORY OF PRESENT ILLNESS Matthew Murphy is a pleasant 20-year-old male who presents to the clinic today for the evaluation of left ankle pain. The onset of his pain began 2 days ago, when he stepped off of a curb and landed on his left ankle wrong. He denies hearing a pop at the time of the injury, however, he describes his ankle as feeling extended and stretched. He was able to ambulate back to his house after the incident but with pain. He denies any previous injuries to his left ankle. His pain is localized to the lateral aspect of his left ankle and can be rated at 8 out of 10 without medication. When taking ibuprofen his pain level is 7 out of 10. He states he has also iced and elevated his ankle. SOCIAL HISTORY Patient reports that he has been working from home since the start of COVID-19 and enjoys taking lots of walks. MEDICATIONS Patient reports taking ibuprofen. REVIEW OF SYSTEMS Musculoskeletal: Patient reports left ankle pain. VITALS Vitals are slightly elevated due to pain level but are otherwise stable. PHYSICAL EXAM NEURO: Normal strength and sensation bilaterally. MSK: Examination of the left ankle: Ecchymosis noted over the lateral malleolus. Edema is present. Tenderness to palpation laterally. No joint laxity appreciated. No bony tenderness to palpation of the foot. Capillary refill is brisk at less than 3 seconds bilaterally. Strong dorsalis pedis pulses bilaterally. RESULTS These reveal no fracture or bony abnormalities. ASSESSMENT Left ankle sprain of the lateral ligament complex. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his symptoms are consistent with an ankle sprain of the lateral ligament complex. The nature of the diagnosis and treatment options were discussed. At this time he will continue to follow the RICE protocol. He will continue to take NSAIDs as needed for pain and swelling. He will also be placed into an Aircast for ankle stabilization and will be provided crutches in order to remain non-weight-bearing. We discussed that it may be a few days before he feels able to tolerate walking. I also advised him that his symptoms will likely start to improve significantly over the next 4 to 6 days. INSTRUCTIONS The patient will follow up with me in 2 weeks to assess his progress, sooner if needed.

aci

D2N065

[doctor] hey anna good to see you today so i'm looking here in my notes says you have you're coming in today for some right ankle pain after a fall so can you tell me what happened how did you fall [patient] yeah so i was taking out the trash last night and i ended up slipping on a patch of ice like and then when i fell i heard this pop and it just hurts [doctor] okay so have you been able to walk on it at all or is it you know [patient] at first no like my friend who was visiting thankfully had to help me get into the house and i you know and now i'm able to put like a little bit of weight on it but i'm i i'm still limping [doctor] okay well you know that's not good we'll we'll hopefully we can get you fixed up here so how much how much pain have you been in on a scale of one to ten with ten being the worst pain you ever felt [patient] it's it's more like so when i first fell it was pretty bad but now it's it's at like a six you know like it's uncomfortable [doctor] okay and how would you describe that pain is it a constant pain or is it only when you move the ankle [patient] it's it's constant it's like a throbbing pain you know and like when i touch it it feels kinda warm [doctor] okay alright yeah but yeah i can feel it here so it does feel a little bit warm so i said you've been in a little bit of pain so have you taken anything for it [patient] well like last night i iced it and i kept it elevated you know i also took some ibuprofen last night and this morning [doctor] alright has the ibuprofen helped at all [patient] not really [doctor] okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before [patient] so you know in high school i used to play a lot of soccer but and and like i had other injuries but i've never injured like this particular ankle before but because i used to play like all the time i knew what i was supposed to do but this is i also knew that it was it was time to come in [doctor] okay yeah yeah definitely if you if you ca n't walk on it we definitely good thing that you came in today and we were able to see you so have you experienced any numbness in your foot at all [patient] no no numbness and i do n't think i've had like any tingling or anything like that [doctor] okay that that's good yeah it sounds like you have sensation there so yeah that that's really good so let me do a quick physical exam on you so i reviewed your vitals your blood pressure was one twenty over eighty which is good your heart rate your spo2 was ninety eight percent which is good that means you're you're getting all of your oxygen and so let me go ahead and look at your ankle real quick so when i press here does that hurt [patient] yeah [doctor] alright what about here [patient] yeah [doctor] okay so looking at your ankle and your right ankle exam on the skin there is ecchymosis so you have that bruising which you can see of the lateral [patient] malleolus [doctor] malleolus associated with swelling there is tenderness to palpation of the anterior laterally in the soft tissue there is no laxity on the anterior drawer and inversion stress there is no bony tenderness on palpation of the foot on your neurovascular exam of your right foot there your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch alright so we did get an x-ray of your ankle before you came in and luckily it's there is no fractures no bony abnormalities which is really good so let me talk a little bit about my assessment and plan for you so for your right ankle pain your symptoms your symptoms are consistent with a right ankle sprain have you sprained your ankle before most times people do the athletics play soccer it happens every so often but have you done that before [patient] no i do n't think so [doctor] okay well you're one of the lucky ones some of my my patients that play sports they sprain their ankle seems like every other week so good for you so for that that that ankle sprain i just want to keep i want you to keep your leg elevated when you're seated and i want you to continue to ice it you can ice it let's say five times a day for twenty minutes at a time just to help that swelling go down i'm gon na give you an air cast to help you stabilize the ankle so keep it from moving and then i'll give you crutches and so i want you to stay off that leg for about one to two days and then you can start walking on it as tolerated tolerated so how does that sound [patient] it's alright [doctor] alright so do you have any questions for me [patient] yeah like how long do you think it's gon na take for me to heal [doctor] i mean it should take a a couple of days i mean i think in a day or two you will be able to walk on it but still think it will be sore for the next couple of weeks you know your ankle sprain seems to be not the worst but it's kinda you know medium grade ankle sprain so as i would say about two to three weeks you should be back to normal you will see some of that bruising go away [patient] yeah okay can i get a doctor's note [doctor] no because you need to go back to work because you work on the computer not running so [patient] fine [doctor] yeah you ca n't get a doctor's note so if you if i write a note i'm gon na tell your boss that you have to go to work [patient] okay thanks [doctor] so i i would n't do that but yeah but otherwise if if if you continue to have pain after this week if you feel like it's not getting better please feel free to contact the office and we can get you back in and possibly do an mri if we you know need to [patient] okay [doctor] alright [patient] alright [doctor] anything else [patient] no that's it [doctor] alright thanks

CHIEF COMPLAINT Right ankle pain. HISTORY OF PRESENT ILLNESS Anna Diaz is a pleasant 31-year-old female who presents to the clinic today for the evaluation of right ankle pain. The onset of her pain began when she slipped on a patch of ice while taking out the trash. She states that she heard a pop at the time of the injury. The patient reports that she was unable to ambulate on her right ankle initially after the injury; however, she is now able to bear some weight on her right ankle, but she is still limping. The patient rates her pain level as a 6 out of 10. Ms. Diaz describes her pain as constant and throbbing. She reports that her right ankle is warm to the touch. She denies any numbness or tingling in her right foot. The patient has been icing and elevating her right ankle while also utilizing ibuprofen last night and this morning, which did not provide her with any relief. The patient states that she used to play a lot of soccer in high school so she notes that she has had other right foot injuries but not like this. REVIEW OF SYSTEMS Musculoskeletal: Positive right ankle pain. Skin: Positive warmth to the right foot. Neurological: Denies any numbness or tingling. VITALS BP: 120/80 SPO2: 98%. PHYSICAL EXAM CV: Capillary refill is less than 3 seconds. Strong dorsalis pedis pulse. NEURO: Normal sensation. Sensation is intact to light touch distally. MSK: Examination of the right ankle reveals ecchymosis over the lateral malleolus associated with swelling. Tenderness to palpation anterolaterally in the soft tissue. No laxity on anterior drawer or inversion stress. No bony tenderness on palpation of the foot. RESULTS X-ray of the right ankle taken in office today reveals no fracture or bony abnormalities. ASSESSMENT Right ankle sprain. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her symptoms are consistent with a right ankle sprain. I have recommended that we treat the patient conservatively. I have advised her to keep her right leg elevated when she is seated. I have also advised her to ice her right ankle 5 times per day for 20 minutes at a time to help with the swelling. I have also recommended that the patient be placed in an Aircast to stabilize the ankle. She will remain non-weight-bearing for 1 to 2 days, we provided her with crutches today, and then she can begin weight-bearing as tolerated. INSTRUCTIONS If her pain does not improve over the next week, she will contact the office and we will obtain an MRI.

aci

D2N066

[doctor] hey gabriel i'm doctor scott good to see you today i know you've heard about dax is it okay if i tell dax a little bit about you [patient] sure [doctor] okay so gabriel is a 43 -year-old male today here for back pain evaluation and also has a past medical history of diabetes high blood pressure and high cholesterol so gabriel tell me what's going on with your back [patient] well i was working in the yard and you know bent over to pick something up and i got this pain and you know across the lower part of my back and then it went down my left leg and you know it's been going on for about four days and just does n't seem to be getting any better [doctor] okay are you a big gardener or this is something that you just started working in the yard [patient] yeah i know my wife held a gun to my head make me go out there work in the yard and carry some stuff around it's not my not my first choice but [doctor] sure sure [patient] but that day i i lost the i lost the argument [doctor] yeah yeah that happens to all of this so when this back pain happened so it was basically you were lifting you were bending down to lift something up and you had the sharp pain going down your right leg you said [patient] left leg [doctor] left leg okay got it sorry and any weakness or numbness in your legs or just the pain mostly [patient] in in certain positions i get some tingling but no mostly just pain [doctor] okay and any loss of bowel or bladder function at all or anything like that [patient] no [doctor] okay and have you had any back surgeries or back problems in the past or this is kind of the first time [patient] no surgeries you know i've i've had back pain occasionally over the years [doctor] okay have you had any any have you tried anything for pain for this have you tried any any medications at all [patient] i've had ibuprofen it it helped some [doctor] okay got it alright well i'll i'll examine you in a second but before we do that let's talk about some of the other conditions that we're kinda following you for i'm looking at your problem list now and you've got a history of diabetes and you're on metformin five hundred milligram twice a day and your how are you doing with your blood sugars and your and your diet and exercise [patient] yeah i i check my sugar two or three times a week most of the time it's in that one twenty to one forty range [doctor] okay [patient] yeah i take my medicine okay my diet is alright you know i could be fifteen pounds lighter that would be alright but [doctor] sure [patient] i i i think the sugar has been okay [doctor] okay we checked your hemoglobin a1c last time i'm looking at your records in epic and it showed that it was you know seven . one so it's it's it's good but it could be better any you know we talked about it controlling your diet or improving your diet and trying to have a balanced meal and not eating some of these sweets and high sugar items how is that going i know you had talked about your wife being a great cook and making cookies and that's hard to stay away from obviously how are things going with that [patient] yeah she still makes cookies and i still eat them but you know we are trying to trying to do better trying to stay away from more of those carbs and focus on you know less carby less sweet stuff [doctor] okay alright yeah that's always a struggle i certainly understand but you know really important with your diabetes just to prevent some of the complications like kidney failure and eye problems and just keep your sugar under balance so i'll order another hemoglobin a1c today we'll check that again today and and you know just reemphasizing the controlling your diet and exercise is super important and then we'll have those results back we'll we'll see if we need to make any modifications okay [patient] okay [doctor] for your high blood pressure your blood pressure in the clinic looks pretty good it's about one twenty over seventy right now we have you on norvasc five milligrams once a day how are things going with that are you are you checking that periodically or any issues with that at all [patient] yeah i guess i check it maybe once a week or two or three times a month and it it the vast majority of the time when i check it it's good usually either that one twenty to one thirty over seventy to eighty range i i think the blood pressure's okay [doctor] okay [patient] i have n't had any real problems there i i have had some some swelling in my ankles though [doctor] okay is that new or is that been going on for a while [patient] well it it started maybe i do n't know a month or two after i started the norvasc [doctor] okay [patient] and i was just wondering if the two might be related [doctor] yeah i mean certainly it could be it is you know sometimes that medication can cause that so i'll i'll examine you in a second and see if we need to make any modifications okay [patient] okay [doctor] alright so and your anything else bothering you today [patient] no i'm we're doing okay i think [doctor] so let me examine you for a second i'm gon na go ahead and gabriel i'm gon na do my magic exam now let's pretend i i'm just gon na verbalize some of my findings as i do my exam and so [patient] these are like my video visit exams [doctor] exactly so your neck exam has no jvd there is no bruits that i can hear your lung exam no rales no wheezing on your heart exam you do have a two over six systolic ejection murmur you had that in the past so i'm not too worried about that otherwise regular rate and rhythm on your heart exam on your on your on your belly exam is nice and soft on your back exam you do have some tenderness on the left paraspinal area right where i'm pressing right there your straight leg raise test is negative your reflexes are normal you have some just some tenderness in the lower back in the paraspinal area of your back when i palpate there otherwise your neurological exam is normal on your extremity exam you do have this one plus nonpitting edema of your lower extremities which is a little bit of swelling in your ankles no calf tenderness negative homans sign no signs of blood clot that's what that means so let me just review what you know explain what all this means so the back pain the first problem that you're here today for i think this is more of a muscular sprain i'm gon na recommend we start you on some anti-inflammatory naprosyn five hundred five hundred milligrams twice a day and flexeril ten milligrams twice a day as well i'm gon na refer you to for for physical therapy to help strengthen some of the muscles in your lower back i do n't think you need an x-ray at this stage why do n't we start with physical therapy and the muscle relaxers and the pain medicines if it does n't get better then we can get an x-ray but right now i would start with that if that's okay with you any questions about that [patient] no [doctor] okay for the diabetes the the second problem that we talked about today i'm gon na order another hemoglobin a1c continue the metformin five hundred milligrams twice a day why do n't we have you come back in about two weeks and we should have some of the results back and we can discuss if we need to make any modifications for that but right now we will continue the course and we will go from there okay for the high blood pressure you do have this one plus edema in your legs i'm gon na go ahead and order some blood work today i'm gon na go ahead and stop the norvasc and we'll put you on some hydrochlorothiazide ten milligrams once a day and if that does n't get if the swelling does n't go away i'm gon na do some more testing for right now let's get some sort off with some cbc and a bmp i'm gon na check your kidney function i'm gon na get another ekg and also i'm gon na get a chest x-ray and we'll go from there but hopefully this will go away once we stop this medication since it started around that time okay okay and i think that's it anything else we forgot about do you need refills for anything [patient] no i i think i'm okay you gave me a year's worth of refills last time we were together [doctor] okay sounds great alright thanks gabriel good seeing you again [patient] good to see you thanks

CHIEF COMPLAINT Back pain evaluation. MEDICAL HISTORY The patient has a history of diabetes, hypertension, and high cholesterol. SURGICAL HISTORY He denies previous back surgeries. MEDICATIONS The patient currently utilizes metformin 500 mg twice daily and Norvasc. REVIEW OF SYSTEMS Cardiovascular: Reports ankle swelling. Musculoskeletal: Reports lower back pain. Neurological: Reports tingling in left leg. Denies weakness or numbness in legs, or loss of bowl or bladder function. PHYSICAL EXAM Neurological - Orientation: Alert and oriented x3. Cranial nerves grossly intact. Normal gait. Neck - General Examination: No JVD. No bruits. Respiratory - Auscultation of Lungs: No wheezes, rales. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. 2/6 systolic ejection murmur. Otherwise, regular rate and rhythm. Musculoskeletal - Examination: Tenderness on the left paraspinal area. Straight leg raise test is negative. Reflexes are normal. 1+ nonpitting edema of lower extremities. No calf tenderness. Negative Homan's sign. ASSESSMENT AND PLAN 1. Lower back pain. - Medical Reasoning: I believe this is more of a muscular sprain. - Patient Education and Counseling: We discussed treatment options today. - Medical Treatment: I am going to start him on Naprosyn 500 mg twice a day and Flexeril 10 mg twice a day. I will refer him for physical therapy to help strengthen some of the muscles in his lower back. - Additional Testing: I do not think he needs an x-ray at this stage, however if he does not improve, we will order one for further evaluation. 2. Diabetes. - Medical Reasoning: His most recent A1c was 7.1 and his blood sugar levels are typically between 120-140. - Patient Education and Counseling: We discussed treatment options today. - Medical Treatment: He will continue the metformin 500 mg twice a day. - Additional Testing: I am going to order another hemoglobin A1c. 3. Hypertension. - Medical Reasoning: He does have 1+ edema in his legs. - Patient Education and Counseling: We discussed treatment options today. I explained that his edema is likely caused by the Norvasc. - Medical Treatment: The patient will discontinue the use of Norvasc and we will start him on hydrochlorothiazide 10 mg once a day. - Additional Testing: I will order a CBC and BMP. Additionally, I will order a repeat EKG, as well as a chest x-ray. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 2 weeks.

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D2N067

[doctor] hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee [patient] yes i hurt my knee when i was skiing two weeks ago [doctor] okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury [patient] so i was flying down this black diamond you know like i like to do [doctor] yes [patient] and this kid who was going faster than me spent by me so then i tried to speed past them and then i ran into a tree and twisted my knee [doctor] so we were downhill skiing racing at this point okay is it your left or your right knee [patient] it's my right [doctor] okay and does it hurt on the inside or the outside [patient] the inside [doctor] okay so the medial aspect of the right knee when you fell did you hear a pop [patient] i did yes [doctor] okay alright [patient] i think that was my left knee [doctor] okay okay alright so we got we got ta pick one if it if it [patient] i'm just trying to be real [doctor] no [patient] what happens in the in a real [doctor] a hundred percent so how about this right now you're like i what i'm hearing is that you're experiencing bilateral knee pain like both of your knees hurt but i'm assuming that like your right knee hurts more is that correct [patient] yeah my left knee does n't really hurt [doctor] uh uh [patient] that's the one that popped it the left knee just feels unstable but my right knee hurts [doctor] gotcha gotcha okay yeah i think hmmm alright so we're gon na we're gon na go ahead and look at this sort of but on a scale of one to ten how severe is your pain [patient] it's a seven [doctor] okay that's pretty bad alright and does it has it been increasing or like rapidly or slowly over the last few days [patient] it's been slow [doctor] okay alright [patient] but sometimes it gets to an eleven [doctor] okay what would do you know if you are doing something that would cause it to be an eleven are you back on your ski's [patient] no i ca n't ski [doctor] okay [patient] usually when i walk my dog [doctor] okay does it hurt more when you walk for longer periods of time [patient] yes [doctor] okay how long does the pain last [patient] for as long as my walk is and i do n't sometimes i walk five minutes kinda depends on the wind [doctor] okay alright [patient] sometimes i walk there is [doctor] okay alright have you done anything to help with the pain [patient] well i wear a brace and i have used a lot of thc cream on it [doctor] okay alright thc cream is an interesting choice but do you think that's been helpful [patient] yes [doctor] alright have you taken [patient] reasons [doctor] not a problem have you taken any medications [patient] no just gummies [doctor] okay like vitamins or more thc [patient] kind of like thc gummies [doctor] thc gummies [patient] my grandma gave them to me [doctor] thc gummies from grandma that's an excellent grandmother that you have okay have you noticed any swelling stiffness tenderness [patient] yeah i i get a lot of swelling and it really is it's very stiff in the morning until i get walking [doctor] okay alright and then have you had any hospitalizations or surgeries in the past [patient] well i had surgery on my right knee before [doctor] okay so you've had surgery before alright do you remember what kind of surgery [patient] i do n't know they told me they reconstructed the whole thing i was fourteen i was a really good gymnast back then really good [doctor] okay [patient] and i was doing a back summer salt and i felt a pop then and then since that time i've really had problems with my knee [doctor] uh uh [patient] but you know the athlete that i am i can still really ski very well so i just kept going [doctor] okay [patient] and i'm really tough my pain tolerance is very high [doctor] okay okay okay how so do you have any other exercises that i might wan na know about outside of intense gym and ski events [patient] no i think that's about it [doctor] okay and how frequently do you normally ski [patient] i ski probably three times a week [doctor] okay and then are you on any medications at this time other than the thc [patient] no [doctor] okay alright what [patient] nothing no [doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and start my examination i'm just gon na call it out for the sake of being able to document it appropriately and you or just just let me know if you want me to explain anything further so with your knee i know that you said it hurts on the right inside a lot right so when i press on the inside of your knee does that hurt [patient] yes [doctor] okay and when i press on the outside of your left of your right knee sorry does that hurt [patient] no [doctor] okay alright so when i move your your kneecap does that hurt [patient] no it kinda makes a shooting pain down to my ankle though [doctor] okay [patient] but it does n't hurt my knee [doctor] okay so does the pain radiate frequently [patient] no [doctor] okay [patient] i've never really noticed it just messed with my kneecap [doctor] okay alright on your skin exam i do appreciate some mild swelling and bruising that's really interesting since it's been two weeks with your knee are you able to bend it [patient] yes [doctor] okay and then when you walked in on your gait i think i think i did appreciate a slight limp are you i i i i think you are you are protecting one of your knees does that sound familiar [patient] yeah i waddle pretty pretty good now [doctor] okay alright and when you move your knee away from your body you're bending like your you're pulling it towards me does that hurt [patient] yes [doctor] okay and then when you pull your knee back towards you does that hurt [patient] no [doctor] alright so pain on dorsiflexion but not on plantar flexion plantar flexion okay alright so what we are gon na do right now i think i'm gon na look at your x-rays but when i when i look at the results of your x-ray i do not appreciate any fracture what i am noticing is the development of a little bit of arthritis and that could explain like why you say that your joints hurt a bit more during like windy weather and what not so this is what we're gon na do for my assessment and plan right the first thing is i think you have a strain of your posterior cruciate ligament what that means is what that will mean for you though is that we are gon na continue to brace your right knee that's gon na hopefully take off some of the stress that you might be putting on it especially since you're limping i am going to recommend you for physical therapy i think it would be an i think it's a good idea to maybe start three times a week to get your strength back into your knee i would recommend not skiing or doing any gymnastics for now and i think that physical therapy will really help considering the injury that you had when you were fourteen i'm gon na prescribe you some medications i do n't necessarily recommend consuming gummies at the same time but the medications i'm gon na give you are gon na be meloxicam fifteen milligrams you're gon na take that once a day that will help with like the swelling and the bruising i'm also gon na prescribe you just like a higher strength nsaid so ibuprofen eight hundred milligrams a day you can take that twice a day as needed for your left knee i think you are i think you just kind of like strength a little bit but like not enough to necessarily require any kind of like medication or bracing i think you just take it easy on your body i know that you're like very active from what i hear and i i think that that's really exciting but i think you might need to listen to your body and give yourself a bit of a break you'll be able to do like several workouts when you go to when you go to physical therapy but you know let the yeah let your therapist be your guide about like what you should and should not be putting your body through does that make sense [patient] yes [doctor] alright do you have any questions right now [patient] no thank you so much [doctor] no problem

CHIEF COMPLAINT Right knee injury. HISTORY OF PRESENT ILLNESS Elizabeth Ross is a pleasant 91-year-old female who presents to the clinic today for the evaluation of a right knee injury. The onset of her pain began 2 weeks ago, when she was downhill skiing. She states she ran into a tree and twisted her right knee. At the time of the injury, she also heard a pop in her left knee, however she denies left knee pain. The patient locates her pain to the medial aspect of her right knee. Currently, her pain level is 7 out of 10, however she notes this can reach an 11 out of 10 at times with prolonged ambulation. The patient states that her pain has been slowly increasing over the last few days. She experiences limping with ambulation. The patient states that her pain lasts for as long as she is ambulating. She denies radiating pain. She also reports constant swelling and stiffness in the morning. Her stiffness will resolve with ambulation. The patient has been wearing a brace and using THC cream, which has been helpful. She denies taking any medications for pain, however she has been utilizing THC gummies, which have been beneficial. The patient has a history of a right knee reconstruction when she was 14 years old. She states that she was a good gymnast at that time. The patient adds that she has had problems with her right knee since that time. She denies any other exercises outside of intense gym and ski events. The patient states that she normally skis 3 times per week. SURGICAL HISTORY The patient reports a history of total right knee reconstruction at the age of 14. MEDICATIONS She denies needing medications. REVIEW OF SYSTEMS Musculoskeletal: Reports right knee pain, swelling, and stiffness. Denies left knee pain. PHYSICAL EXAM MSK: Examination of the right knee: Mild effusion. The patient ambulated with an antalgic gait. Pain with dorsiflexion, but not with plantarflexion. RESULTS 4 views of the right knee were taken. These reveal no evidence of any fractures. There is development of mild arthritis. ASSESSMENT 1. Right knee posterior cruciate ligament strain. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have explained to her that her x-rays did not reveal any signs of a fracture. I have recommended that we treat the patient conservatively with continued bracing. We will initiate formal physical therapy 3 times per week to strengthen her right knee. Additionally, I have prescribed the patient meloxicam 15 mg and ibuprofen 800 mg twice daily as needed. She should discontinue the use of her THC gummies while taking these medications. Regarding her left knee, I do not believe she will need any further medications to treat this. I have advised her to avoid skiing or gymnastics at this time.