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[doctor] kayla ward , date of birth , 4/28/07 . mrn 3-8-4-9-2-0 . she's here for a new visit with her mother for acne located on the face , which started about two years ago and is present most every day . she has been using persa-gel and washing regularly , which is somewhat helpful . there are no associated symptoms including itching , bleeding , or pain . no additional past medical history . she lives with her parents and sister . they have a dog , bird , and bunnies . she is in 7th grade . she plays basketball and volleyball and tap . she wears sunscreen in the summer , spf 30 . no additional family history . hi kayla , i'm dr. juan price . i hear you are starting to get some acne on the face . how about the chest and back ? [patient] it's not too bad . [doctor] so , it's not bad on the chest or back . you've used some over the counter items like washes and persa-gel ? [patient] yeah . [doctor] do those seem to be helping ? [patient] yes , i think so , a little bit . [doctor] good . what's your skin care routine like now ? [patient] do you wan na know , like , the things i currently use ? [doctor] yes . what do you do for your acne in the morning ? and then what do you do at nighttime ? [patient] i wash my face , more like i wipe it down in the morning . then at night i use an elf facial cleanser called the super clarity cleanser . i finish with a toner and then the persa-gel . [doctor] when you say , " wipe your face in the morning , " do you use a product or just water ? [patient] mm , just water and a washcloth , really . if i feel really greasy , sometimes i'll use the elf cleanser in the morning , too . [doctor] okay . and is today a good day , bad day , or an average day for you ? [patient] mm , i would say it's probably a good day for me , of course , since i'm here , right ? [doctor] acne is always good when you come to see the doctor . do you find that your acne flares with your periods ? [patient] no , not really . [doctor] and do you get a regular period ? [patient] yup . [doctor] how long have you been getting a regular period ? [patient] mm , i think about two years . [doctor] okay . [patient_guest] the biggest flare , probably , was when she started school sports in the fall , just with all the sweating . [doctor] yup , that will do it . is there anything else that you've noticed , mrs. ward ? [patient_guest] no . kayla really has been doing a good job with the facial care regimen . it just does n't seem to help as much as we wanted . [doctor] got it . okay . well , let's take a look then . full exam is performed today , except for under the underwear and under the bra . multiple benign nevi on the trunk and extremities . scattered skin colored papules . open and closed comedones . and erythmateous papules on the face , primarily on the forehead and with also some on the central cheeks and chin . the chest and back are relatively spared . and the remainder of the examination is normal . so , what i'm seeing from your exam today is mild to moderate acne , mostly comodonal with small inflammatory component . [patient] okay , so is there anything we can do to help it ? [doctor] yes . i would like to start with a topical therapy first . every morning , you will wash your face with a mild cleanser then use a moisturizer labeled , " noncomedogenic , " with sunscreen spf 30 or higher . this means it wo n't clog your pores . now , in the evening , wash your face with the same cleanser and allow it to dry . apply adapalene , 0.1 % cream , in a thin layer to the areas you generally get acne . i want you to start off using this a few nights a week and slowly work up to using it every night . if it is ... excuse me , if it is very expensive or not covered by insurance , you can try different gel over the counter . you can follow that with clean and clear persa-gel in a thin layer , or where you generally get acne . and then a noncomedogenic moisturizer . you're atopic retinoid will cause some sensitivity , so you will need to wear sunscreen when you are outside . it may also cause some dryness or irritation . [patient] okay , i can do that . [doctor] you also have multiple benign moles on your arms , legs , back and abdomen . this means they all look normal with no worrisome features . we will see if you have any progress over the next six months and follow up at that time . [patient] okay , that sounds good . thank you . [doctor] do you have any questions for me ? [patient] no , i do n't think so . [doctor] okay . if you have questions or concerns before your next visit , please call the office . [patient] thank you , doctor , we will .

HISTORY OF PRESENT ILLNESS Matthew Hill is a pleasant 44-year-old male who presents to the clinic today for the evaluation of back pain. The patient was referred from his primary care physician. The onset of his pain began 30 years ago, when he fell off of a roof. He endorses that it was very bothersome and he was unable to play football. He states that he was told that he may have a fracture at that time. The patient reports that his pain has worsened 1 month ago. He locates his pain to his lower back, which radiates into his left hip, down his left leg, on the side of his calf, and into his left big toe. The patient describes his pain as an "electrical tooth ache" that radiates down his entire left leg. He notes that he has to use a cane to walk as his left foot drags when he walks. He rates his pain level as a 6 to 8 out of 10, however it can get to a 13 out of 10 at its worst. He states that he did not take any medication before his appointment so it did not affect his pain during our visit. The patient notes that he was in the waiting room for 30 minutes today and states that it made his symptoms worse. His pain is aggravated by standing, ambulating, coughing, and sneezing. The patient states that he is unable to tie his shoes secondary to the pain. The patient states that his pain is alleviated by lying down. He also reports weakness in his bilateral legs and his back. The patient denies any numbness or tingling. The patient has attempted NSAIDs in the past without relief. He has also attended physical therapy. PHYSICAL EXAM CONSTITUTIONAL: Vitals look good. MSK: Examination of the lumbar spine: No bony abnormalities. No redness. No bruising present. Pain with palpation at the L4 vertebrae. Positive for pain with flexion and extension of the back. 4/5 strength on the left, 5/5 strength on the right. Reflexes are brisk. Motor and sensory are intact throughout the bilateral lower extremities. RESULTS The MRI of the lumbar spine was reviewed today. It revealed a disc herniation at the level of the L4-5 vertebrae. It is associated with some nerve root impingement. ASSESSMENT Acute disc herniation at L4-5 with nerve root impingement. PLAN I have recommended that we treat the patient conservatively with a epidural steroid injection and formal physical therapy. With the patient's consent, we will proceed with a epidural steroid injection into the lumbar spine today. He will follow up with me in 4 weeks to check on his progress.

[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 Annual exam. HISTORY OF PRESENT ILLNESS The patient is a 62-year-old male with a past medical history significant for depression and prior lobectomy, as well as hypertension. He presents for his annual exam. The patient reports that he is doing relatively well. Over the summer, he moved his oldest daughter into college which was a little stressful and chaotic in the heat of the summer. Regarding his depression, he reports that he has been consistent with his Prozac and has not had any incidents in a while. His hypertension has been slightly uncontrolled. He reports that he is taking his blood pressure at home and it is running high. The patient states that he is pretty regular with his Norvasc during the business week, but on the weekends he will forget to bring it with him. He reports that he had a prior lobectomy a couple of years ago. He endorses shortness of breath with exertion. The patient has difficulty breathing due to allergies and the heat in the summertime. He also endorses some nasal congestion from the pollen. He reports that he runs in the morning. Occasionally, if it is relatively humid, he will struggle a little bit with breathing and he will feel a little bit of a pounding in his chest. He states that it usually goes away. He reports that he runs 4 to 5 miles a day. REVIEW OF SYSTEMS • Ears, Nose, Mouth and Throat: Endorses nasal congestion from the pollen. • Cardiovascular: Endorses intermittent palpitations. Endorses dyspnea on exertion. • Respiratory: Endorses shortness of breath. Endorses cough. • Psychiatric: Endorses depression. PHYSICAL EXAMINATION • Head and Face: Pain to palpation to the sinuses. • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Regular rate. 2/6 systolic ejection murmur. No gallops or rubs. No extra heart sounds. VITALS REVIEWED • Blood Pressure: 124/80 mmHg. RESULTS Electrocardiogram stable. X-ray of the chest is unremarkable. ASSESSMENT AND PLAN Ralph Barnes is a 62-year-old male who presents for his annual examination. Annual visit. • Additional Testing: I have ordered his routine blood work and will follow up with the patient via the portal once results are back. Depression. • Medical Reasoning: He is doing well with his current regimen. • Medical Treatment: He can continue Prozac 20 mg a day and I provided a refill of that today. History of lobectomy. • Medical Reasoning: I do not think we need to do any more work up for this issue. He is able to exercise a lot and his breathing function is back. I do not think he needs to follow up with the surgeon anymore. Hypertension. • Medical Reasoning: He is doing well on his current regimen. His blood pressure was normal today and has been trending well over the past several years. • Additional Testing: I ordered an echocardiogram to evaluate his murmur. • Medical Treatment: He can continue Norvasc. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[doctor] hi jerry , how are you doing ? [patient] hi , good to see you . [doctor] good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you . [patient] sure . [doctor] jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sclerosis who presents for an annual exam . so jerry , what's been going on since the last time i saw you ? [patient] uh , we have been traveling all over the country . it's been kind of a stressful summer . kinda adjusting to everything in the fall and so far it's been good , but ah , lack of sleep , it's been really getting to me . [doctor] okay . all right . and have you taken anything for the insomnia . have you tried any strategies for it . [patient] i've tried everything from melatonin to meditation to , uh , t- stretching out every morning when i get up . nothing really seems to help though . [doctor] okay . all right . [doctor] in terms of your osteoporosis , i know we have you on fosamax , any issues with your joints , any issues like- [patient] no . [doctor] no broken bones recently ? [patient] no . [doctor] no , nothing like that ? [patient] no . [doctor] okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ? [patient] uh , about six months ago . [doctor] okay and you're taking the medication ? [patient] yes . [doctor] okay . and any issues with that ? [patient] none whatsoever . [doctor] and any additional weakness ? i know you were having some issues with your right leg , but that seems to have improved or ? [patient] yes a lingering issue with my knee surgery . but other than that it's been fine . [doctor] okay . [patient] pretty , pretty strong , n- nothing , nothing out of the ordinary . [doctor] okay . all right , well i know you did a review of systems sheet when you checked in . [patient] mm-hmm . [doctor] and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ? [patient] no . [doctor] all right . well lets go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find . [patient] sure . [doctor] okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee . [patient] mm-hmm . [doctor] um , so let's go over some of your results , okay ? [patient] sure . [doctor] hey dragon , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . do you need a refill on that ? [patient] actually i do . [doctor] hey dragon , order a refill of fosamax 1 tab per week , 11 refills . and then in t- , for your second problem , your multiple sclerosis i want you to go ahead and continue to see the neurologist and continue on those medications . and let me know if you need anything from that standpoint , okay ? [patient] you got it . [doctor] any questions ? [patient] not at this point , no . [doctor] okay , great . hey dragon , finalize the note .

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.

[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 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.

[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

CC: Right knee pain. HPI: Ms. Thompson is a 43-year-old female who presents today for an evaluation of right knee pain. She states she was trying to change a lightbulb on a ladder, and she twisted her knee when she stumbled and caught herself from falling yesterday. She has been applying ice and taking Ibuprofen without relief. CURRENT MEDICATIONS: Ibuprofen, digoxin. PAST MEDICAL HISTORY: Atrial fibrillation. PAST SURGICAL HISTORY: Rhinoplasty. EXAM Examination of the right knee shows pain with flexion. Tenderness over the medial joint line. No pain in the calf. Pain with valgus stress. Sensation is intact. RESULTS X-rays of the right knee show no obvious signs of acute fracture or dislocation. Mild effusion is noted. IMPRESSION Right knee acute medial meniscus sprain. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a knee brace. She will take Motrin 800 mg, every 6 hours with food, for two weeks. She will use crutches for the next couple of days. She will follow up with me in 1 week for a repeat evaluation. If she is not better at that time, we will obtain an MRI. All questions were answered.

[doctor] alright so how're you doing today angela [patient] i'm doing pretty well [doctor] alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on with your kidneys you as what how long ago have you been feeling pain and and how's all that [patient] pain's been up and down i went to the emergency room last week but now i think i'm doing a little bit better [doctor] okay so the case of kidney stones so have you had you said you've had them in the past and how often would you say [patient] i do n't know i this is probably like my seventh or eighth kidney stone [doctor] seven or eight kidney stones so do you think you passed it yet or is it still in the [patient] i think this one passed yeah [doctor] this one passed how long would you say it took to [patient] well i went last week and then i think it passed about three days ago [doctor] okay so are you still noticing any blood in your urine [patient] no no more blood [doctor] alright are you still having pain [patient] nope [doctor] yeah [patient] the pain's gone [doctor] okay that that's that's that's really good did they do anything for you at the hospital giving you any medications [patient] they gave me some pain medicine [doctor] okay do you remember what it was [patient] i think it was percocet [doctor] okay well that's good i'm very glad to see that you were able to pass that stone have you seen a urologist before about this [patient] i have n't seen one in a while but yes i saw someone maybe a year ago [doctor] okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well [patient] okay [doctor] so i also see you're here for you have a past medical history of of hypertension and when you came in today your blood pressure was a little bit high it was a one fifty over ninety i'm reading here in your chart you're on two point five of norvasc [patient] hmmm [doctor] now have you been taking that regularly [patient] i have but at home my blood pressure is always great [doctor] okay maybe you have a little white coat syndrome some of my patients do have it i have it myself and i'm a provider so i definitely understand yeah i know we we talked about last time you getting a blood pressure cuff and taking those about two to three times a week so what have those readings been i'm usually like one thirty to one forty over sixty to seventy [patient] okay [doctor] that's that's that's not too bad i think when you first came in you were around like one eighty so it seems to be that that norvasc is is working for you how about your diet i know you were having a little issue eating some fast food and and cakes and cookies and have you been able to get that under control [patient] yeah it's hard to give up the fast food altogether because it's a lot of on the go you know [doctor] okay so do you think you would be able to get that under control by yourself or would you do you think you would need help with that maybe a dietitian be able to help you out [patient] yeah i do n't know i do n't know if i can make another appointment i just add to the extra [doctor] okay [patient] less time to make food so [doctor] yeah yeah definitely understand [patient] mm-hmm [doctor] alright yeah so i mean that's one thing we just got ta work one is your diet we try to keep you at least just twenty three hundred milligrams or less of sodium per day i know that's hard for a lot of salads and stuff i know it's hard for lot of people especially with all like the the prepackage foods we have around today so that's definitely something we we should work on [patient] mm-hmm [doctor] so let's also look here you have a history of diabetes and so you're on that five hundred milligrams of metformin daily now have you been taking that as well [patient] yeah i take my metformin [doctor] okay [patient] yeah [doctor] so what have your blood sugars been running daily [patient] well i do n't check it very often [doctor] okay [patient] but i think they've been pretty good [doctor] okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam on you before i do just wan na make sure are you having any chest pain today [patient] no [doctor] alright any any belly pain [patient] no [doctor] alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na just press here in your abdomen because that you did have those kidney stones does that hurt [patient] no [doctor] alright i'm gon na press here on your back [patient] no pain [doctor] okay so on your abdomen exam of your abdomen i'm showing no tenderness to palpation of the abdomen or tenderness of the the cva either on the right side so that that's good i think that's pretty much cleared up so let's we'll talk a little bit about my assessment and plan for you and so my assessment you you did have the those kidney stones but i i think they are passed this time but i do want to get a couple of labs so we'll get a urinalysis [patient] okay [doctor] alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology [patient] okay [doctor] because you do keep having these all the time and so maybe there's something else going wrong and so they can help get that under control [patient] can i see doctor harris [doctor] of course yeah we can we can get you that road to doctor harris and [patient] he's not like [doctor] he's great he's he's he he he's great i've heard he does really good work so that'll be good so for the hypertension you seem to be doing well on the two . five of norvasc so we are not gon na make any changes to that do you need any refills right now [patient] no usually the pharmacy just sends them through when i call [doctor] okay great so we we wo n't we gave you refills with that i do wan na give you a consult to nutrition [patient] okay [doctor] just to help you with that diet [patient] okay [doctor] because i think that's a major factor of us eventually getting you off of all medications [patient] hmmm [doctor] and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal [patient] okay [doctor] just to gauge where you are so you can tell how much food you should actually be be eating [patient] okay [doctor] alright [patient] i can try that [doctor] so how does that that sound [patient] that sounds like a plan when should i come back and see you [doctor] so you can you can come back in three months and we'll check up again i forgot you did tell me last time that you were having some issues with insomnia [patient] hmmm [doctor] how is that going for you is it still happening [patient] i mean sometimes i stay awake just kinda worrying about things but but i've tried some meditation apps and that helps [doctor] okay alright and i know we talked a little bit before about practicing proper sleep hygiene you know just making sure that all of your electronics are off you know dark room [patient] yeah [doctor] cool room have you been doing that [patient] well i do like to sleep with the tv on and my phone is right by my bed because i never know if someone's gon na call me you know [doctor] yeah i i know i'm like apple i do n't know if you have an iphone or not but i know apple has this the the sleep mode now do that disturbance so you put that on [patient] it's a good idea [doctor] interrupt you [patient] yeah [doctor] okay have you tried taking melatonin to sleep [patient] i used it a couple times but but it did n't seem to help that much [doctor] okay how about i do n't think i've prescribed you anything yet do you think you would need anything [patient] hmmm i do n't really wan na take any sleeping pills [doctor] okay that's understandable alright so for the last issue for the insomnia i'm just gon na have you take ten milligrams of melatonin as needed [patient] okay [doctor] and just try i guess the best as possible to practice the proper sleep hygiene so you can get to sleep at night and and feel pretty rested [patient] okay [doctor] alright [patient] mm-hmm [doctor] so do you have anything any other questions for me [patient] no that's all [doctor] alright so we will see you in three months [patient] okay sounds good [doctor] alright [patient] like

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.

[doctor] hi logan . how are you ? [patient] hey , good to see you . [doctor] it's good to see you as well . [doctor] 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] so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain . [patient] mm-hmm . [doctor] so logan , what happened to your back ? [patient] uh , we were helping my daughter with some heavy equipment and lifted some boxes a little too quickly , and they were a little too heavy . [doctor] okay ... and did you strain your back , did something- [patient] i thought i heard a pop when i moved and i had to lie down for about an hour before it actually relieved the pain . and then it's been a little stiff ever since . and this was- what , so today's tuesday . this was saturday morning . [doctor] okay , all right . [doctor] and is it your lower back , your upper back ? [patient] my lower back . [doctor] your lower back , okay . and what- what have you taken for the pain ? [patient] i took some tylenol , i took some ibuprofen , i used a little bit of icy heat on the spot but it really did n't seem to help . [doctor] okay . and um ... do you have any numbing or tingling in your legs ? [patient] uh ... i felt some tingling in my toes on my right foot until about sunday afternoon . and then that seemed to go away . [doctor] okay , and is there a position that you feel better in ? [patient] uh ... it's really tough to find a comfortable spot sleeping at night . i would- i tend to lie on my right side and that seemed to help a little bit ? [doctor] okay , all right . [doctor] well , um ... so how are you doing otherwise ? i know that , you know , we have some issues to talk- [patient] mm-hmm . [doctor] . about today . were you able to take any vacations over the summer ? [patient] um ... some long weekends , which was great . just kind of- trying to mix it up through the summer . so lots of three day weekends . [doctor] okay , well i'm glad to hear that . [doctor] um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ... [patient] yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar . [patient] and uh ... i-i think i need to go clean for a couple of weeks . but other than that , it was been- it's been pretty good eating . [doctor] okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ? [patient] i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , but it's been pretty good and-and under control for the most part . [doctor] okay , and you're you're taking your medication ? [patient] yes , i am . [doctor] okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ? [patient] uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . not great , but it's been okay . [doctor] okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain . [doctor] have you had any other symptoms , chest pain , nausea or vomiting- [patient] no . [doctor] . fever , chills ? [patient] no . no none whatsoever . [doctor] no . okay . all right , well let me go ahead , i want to do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon ? show me the blood pressure . [doctor] so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your- [patient] mm-hmm . [doctor] . blood pressure go up . let's look at the readings . [doctor] hey dragon ? show me the blood pressure readings . [doctor] yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well . [patient] mm-hmm . [doctor] okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ? [patient] sure . [doctor] and kick against my hands . [doctor] okay , good . all right . [doctor] okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur . [patient] mm-hmm . [doctor] on your heart exam . which you've had in the past . [patient] mm-hmm . [doctor] so that sounds stable to me . [doctor] on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? [patient] mm-hmm . [doctor] hey dragon ? show me the diabetes labs . [doctor] okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? [patient] sure . [doctor] hey dragon ? show me the back x-ray . [doctor] so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- [patient] mm-hmm . [doctor] . the history , okay ? [patient] mm-hmm . [doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . [doctor] so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . [patient] mm-hmm . [doctor] i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- [patient] mm-hmm . [doctor] . and see how you do , okay ? [patient] you got it . [doctor] for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ? [patient] mm-hmm . [doctor] hey dragon ? order a hemoglobin a1c . [doctor] so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day . [patient] mm-hmm . [doctor] does that sound okay ? i think we need to get it under better control . [patient] no that's fine . i agree . [doctor] hey dragon ? order lisinopril 20 mg daily . [doctor] and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ... [patient] mm-hmm . [doctor] i do n't think we need to do any- any further , you know , work up of that at this time , okay ? [patient] mm-hmm . [doctor] do you have any questions logan ? [patient] not at this point . [doctor] okay . all right . [doctor] so the nurse will come in to help you get checked out , okay ? [patient] you got it . [doctor] hey dragon ? finalize the note .

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.

[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 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.

[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 Pituitary lesion. HISTORY OF PRESENT ILLNESS Bruce Ward is a 52-year-old male with a pituitary lesion. The patient is seen in consultation at the request of Dr. Henry Howard for possible surgical intervention. The patient presented to his primary care provider, Dr. Howard, on 03/01/2021 complaining of worsening headaches over the past few months. He denied any trouble with headaches in the past. Further work up of headaches with MRI of the brain revealed the pituitary lesion. Mr. Ward reports headaches started about 3 months ago, at which point they were around 3 out of 10 in severity. They have gradually worsened over time and now he rates them at about 6/10. The headaches do tend to be worse in the morning and feel like a dull ache behind the eyes. They tend to last a few hours at a time, and nothing makes them particularly worse or better. Tylenol failed to improve headaches. The patient endorses that recently he has been bumping into door frames, but no obvious problems with his balance or vision. He denies any recent sickness or feeling sick and negative for fever, rash, paresthesia, weakness, neck stiffness, or syncope. PAST HISTORY Medical Newly diagnosed pituitary lesion. FAMILY HISTORY No known family history; adopted. SOCIAL HISTORY Employment Status: Works as a computer programmer. Marital Status: Married for 25 years. Living Arrangement: Lives with wife, recently purchased a new house. Alcohol Use: None. Tobacco Use: Non-smoker. Recreational Drugs: None. PHYSICAL EXAM Neurological Patient alert, oriented to person, place, and time, affect appropriate and speech fluent. Cranial nerve examination grossly intact. No focal motor or sensory deficit in the upper or lower extremities. Eyes Visual acuity and eye movements are normal. Pupils are equal and reactive. Visual field testing reveals bitemporal hemianopia. Color vision is normal. RESULTS Labs reviewed, 03/03/2021: CBC, U&Es, coagulation, and CRP are all normal. Pituitary hormone profile demonstrates a low TSH, all other results were normal. Independent review and interpretation of MRI brain, 03/04/2021: The MRI reveals a pituitary lesion with elevation and compression of the optic chiasm. The ventricles are normal in size and no other abnormalities are noted. ASSESSMENT • Pituitary adenoma • Bitemporal hemianopia Mr. Ward is a very pleasant 52-year-old male who has a benign appearing pituitary adenoma discovered on work up for worsening headaches. There is clinical and radiographical evidence of optic chiasmal compression, examination today revealed a bitemporal hemianopia. Radiographically this appears to be a benign pituitary adenoma but that there was no way to be sure without a pathological diagnosis. Surgical intervention to excise and decompress the pituitary fossa is indicated given optic chiasmal compression. PLAN Pituitary adenoma. We discussed the general indications for surgical intervention. The risks, benefits to trans-sphenoidal resection were explained to the patient. The risks of anesthesia including but not limited to the risks of heart attack, stroke, and death. The risks of surgery including infection, need for further surgery, wound issues (such as spinal fluid leak or infection) which may require prolonged hospitalization or additional procedure, seizure, stroke, permanent numbness, weakness, difficulty speaking, or death. The patient voiced understanding and wishes to proceed with trans-sphenoidal resection of the adenoma. Bitemporal hemianopia. We will have the patient scheduled this week to have visual field testing with ophthalmology. The preoperative visual field will serve as baseline for comparison of postoperative visual field testing to monitor for improvement in the bitemporal hemianopia. Additionally, we discussed that unfortunately no guarantees could be given that his vision would return. INSTRUCTIONS • Refer to ophthalmology for baseline visual field testing. • Schedule trans-sphenoidal resection of pituitary adenoma.

[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 elbow pain. HISTORY OF PRESENT ILLNESS Lawrence Butler is a pleasant 45-year-old male who presents to the clinic today for the evaluation of right elbow pain. Over the past week, the patient has developed 6/10 pain in the "inside" of his right elbow. The pain may radiate into his forearm on occasion, but does not extend up to his shoulder. He denies any history of trauma or injury, but he did start making pottery during the COVID-19 pandemic and suspects that his symptoms could be related to that. His symptoms affect his ability to lift objects or perform his typical activities of daily living. Ibuprofen provides minimal symptomatic relief. SOCIAL HISTORY The patient reports that he began making pottery during the COVID-19 pandemic. MEDICATIONS The patient reports that he has been taking ibuprofen. REVIEW OF SYSTEMS Musculoskeletal: Reports right elbow pain. VITALS Normal PHYSICAL EXAM MSK: Examination of the right elbow: Moderate tenderness at the medial epicondyle. No pain with supination of the forearm. Pain with pronation of the forearm. Pain with resistance against flexion of the wrist. RESULTS X-ray imaging of the right elbow was obtained and reviewed in office today. These reveal no evidence of fracture or bony abnormality. ASSESSMENT Right medial epicondylitis. PLAN The patient and I discussed his diagnosis in detail, and I explained that his symptoms are likely caused by overuse and potential damage of the tendons. We will provide him with sling to be worn during the day while he is awake. I want him to take ibuprofen 600 mg every 6 hours with food for a full week and ice the elbow for 20 minutes, 3 times daily. Finally, I advised the patient to rest his elbow and avoid doing any pottery for the next couple of weeks. INSTRUCTIONS The patient will follow up in 1 week.

[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

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.

[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 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.

[doctor] hi jerry , how are you doing ? [patient] hi , good to see you . [doctor] good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you . [patient] sure . [doctor] jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sclerosis who presents for an annual exam . so jerry , what's been going on since the last time i saw you ? [patient] uh , we have been traveling all over the country . it's been kind of a stressful summer . kinda adjusting to everything in the fall and so far it's been good , but ah , lack of sleep , it's been really getting to me . [doctor] okay . all right . and have you taken anything for the insomnia . have you tried any strategies for it . [patient] i've tried everything from melatonin to meditation to , uh , t- stretching out every morning when i get up . nothing really seems to help though . [doctor] okay . all right . [doctor] in terms of your osteoporosis , i know we have you on fosamax , any issues with your joints , any issues like- [patient] no . [doctor] no broken bones recently ? [patient] no . [doctor] no , nothing like that ? [patient] no . [doctor] okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ? [patient] uh , about six months ago . [doctor] okay and you're taking the medication ? [patient] yes . [doctor] okay . and any issues with that ? [patient] none whatsoever . [doctor] and any additional weakness ? i know you were having some issues with your right leg , but that seems to have improved or ? [patient] yes a lingering issue with my knee surgery . but other than that it's been fine . [doctor] okay . [patient] pretty , pretty strong , n- nothing , nothing out of the ordinary . [doctor] okay . all right , well i know you did a review of systems sheet when you checked in . [patient] mm-hmm . [doctor] and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ? [patient] no . [doctor] all right . well lets go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find . [patient] sure . [doctor] okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee . [patient] mm-hmm . [doctor] um , so let's go over some of your results , okay ? [patient] sure . [doctor] hey dragon , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . do you need a refill on that ? [patient] actually i do . [doctor] hey dragon , order a refill of fosamax 1 tab per week , 11 refills . and then in t- , for your second problem , your multiple sclerosis i want you to go ahead and continue to see the neurologist and continue on those medications . and let me know if you need anything from that standpoint , okay ? [patient] you got it . [doctor] any questions ? [patient] not at this point , no . [doctor] okay , great . hey dragon , finalize the note .

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.

[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 .

CHIEF COMPLAINT Right wrist injury. HISTORY OF PRESENT ILLNESS Diana Scott is a pleasant 61-year-old female who presents to the clinic today for the evaluation of a right wrist injury. The patient sustained this injury yesterday morning, 05/12/2022, when she slipped on the stairs while carrying a laundry basket. She states she tried to catch herself with her arms outstretched. The patient reports an immediate onset of pain and swelling in her right wrist. She denies any previous injuries to her right arm. The patient rates her pain level as a 9/10. Her pain is aggravated by movement. The patient also reports numbness and tingling in her fingers. She has been icing and wrapping her right wrist with an ACE wrap. The patient has also been taking ibuprofen, which provides some relief. She notes fully extending her arm while resting it on a pillow alleviates some of her pain as well. The patient is going on vacation in 1 month. REVIEW OF SYSTEMS Musculoskeletal: Reports right wrist pain and swelling. Neurological: Reports numbness and tingling to the digits of the right hand. VITALS Blood Pressure: Elevated at 140/70 mmHg. Heart Rate: 80 beats per minute. Respiratory Rate: 20 breaths per minute. Body Temperature: 97.2 degrees F. HEAD: Normocephalic NECK: No swelling noted CV: No bilateral lower extremity edema. No carotid bruit. No murmurs, gallops or rubs heard during auscultation of the heart. Palpabale pulses to the bilateral lower extremities. RESPIRATORY: Normal respiratory effort no respiratory distress. Lungs clear to auscultation bilaterally. GI/GU: Non-distended BACK: No evidence of trauma or deformity NECK: No adenopathy. No thyromegaly. MSK: Examination of the right wrist: Limited range of movement. Tenderness to palpation. Pain on flexion and extension. Pain with radial deviation and lateral deviation. Pain with wrist abduction and adduction. The metacarpals are intact. Obvious swelling and bruising. Tenderness on palpation throughout. There is evidence of potential fracture feeling and bony crepitus. RESULTS X-rays of the right wrist were taken today. These reveal the fracture appears extra-articular and proximal to the radioulnar joint. Dorsal angulation of the distal fracture fragment is present to a variable degree. Dorsal angulation is severe, presenting with a dinner fork deformity. An ulnar styloid fracture is present. ASSESSMENT Right wrist Colles fracture. PLAN After reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays revealed a right wrist Colles fracture. We discussed treatment options and I have recommended that we proceed with a right wrist ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I explained that we should schedule the operation for as soon as possible to ensure adequate healing and to limit malformation of the wrist. I advised that this procedure will require her to be admitted to the hospital for an overnight stay. In the meantime, the patient will be placed in a thumb spica brace and receive instructions on its proper usage. I have prescribed the patient Ultram 50 mg every 6 hours to treat her pain. We also discussed that her postoperative course will include wearing a brace for 6 weeks. A few weeks after surgery, the patient will initiate formal physical therapy and will attend 3 times per week to strengthen her right wrist. The patient has a 2-week vacation planned in 1 month. I recommended that we consult with her physical therapist to determine if there are exercises she can perform on her own instead of postponing her vacation. INSTRUCTIONS The patient will follow up with me in 4 weeks status post surgery to discuss her progress.

[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 Headaches. HISTORY OF PRESENT ILLNESS Julie Jenkins is a pleasant 33-year-old female who presents to the clinic today for the evaluation of headaches. The patient was referred from her primary care physician. The patient states that she was seen by Dr. White a few years ago and was going to obtain an MRI; however, Dr. White wanted her to see me first and urgently. The onset of her headaches began when she was a teenager. Initially, her headaches appeared during menses, however she now experiences them more frequently and with more severity. Her pain is aggravated by physical activities. The patient states that she has been trying to exercise more in order to lose weight, however she is unable to exercise for prolonged periods of time secondary to the headaches. The patient locates her pain to the right side of her head and behind her eye. She describes her pain as a pulsing sensation. She also reports intermittent ringing in her ears for the last few months. Additionally, she reports intermittent blurred vision on the lateral aspect of her vision. She denies any numbness or tingling in her hands, feet, or face. The patient enjoys running and wears either New Balance or Asics shoes. REVIEW OF SYSTEMS Neurological: Reports headaches. Denies numbness or tingling in her hands, feet, or face. VITALS Vitals are within normal limits. PHYSICAL EXAM CV: Normal head rhythm with no murmurs, rubs, or gallops. NEURO: Cranial nerves I through XII are intact distally, including a normal cranial reflex. MSK: Gait is normal. Funduscopic exam: Positive for papilledema. ASSESSMENT Headaches, concern for idiopathic intracranial hypertension. PLAN After reviewing the patient's examination today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have recommended that we obtain an urgent MRI of the brain to evaluate for any other condition that could be contributing to her symptoms. We will contact her to schedule this after approved by insurance. Once the MRI results are available for review and further discussion, I will also perform a spinal tap to evaluate the pressure in the brain. I have also advised her to be seen by a neuro ophthalmologist for a complete eye exam. Questions were invited and answered today. The patient agrees to the treatment plan. INSTRUCTIONS The patient will follow up with me once the MRI results are available for review and further recommendations.

[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 Low back pain. HISTORY OF PRESENT ILLNESS Bryan Brooks is a pleasant 39-year-old male who presents to the clinic today for the evaluation of low back pain. He is accompanied today by his partner. Approximately 2 hours after he finished raking leaves yesterday, the patient began to feel a tightening sensation in his low back and tingling in his right foot. Prior to this, he recalls a similar episode approximately 3 years ago in which his symptoms resolved after 1 day. Ice and Advil provided no relief, but his pain is less severe when he is in a seated position and taking a hot shower helped alleviate his pain. The patient's partner reports that his pain seems to worsen when he stands up. REVIEW OF SYSTEMS Musculoskeletal: Reports low back pain. Neurological: Reports tingling in the right foot. PHYSICAL EXAM NEURO: Normal strength and sensation. MSK: Examination of the lumbar spine: No pain on extension. Some pain with flexion. Pain with palpation around L5. Dorsiflexion is normal. Pulses are equal in all extremities. RESULTS X-rays obtained and reviewed in office today were normal. ASSESSMENT Low back sprain. PLAN The examination findings and x-ray results were discussed with the patient and his partner today. I recommend we treat this conservatively with rest, meloxicam, and formal physical therapy. If he fails to improve, we can consider obtaining an MRI for further evaluation. INSTRUCTIONS The patient will follow up in 2 weeks.

[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 .

CC: Right finger pain. HPI: Ms. Brooks is a 48-year-old female who presents today for an evaluation of right finger pain. She states she was skiing on Sunday and hyperextended her finger when it became caught in a strap on a jump. She has tried applying ice and taking Ibuprofen, but it is still very painful. She has pain with movement. CURRENT MEDICATIONS: MiraLax PAST MEDICAL HISTORY: Constipation. PAST SURGICAL HISTORY: Appendectomy. EXAM Examination of the right index finger shows tenderness over the distal phalanx. No tenderness over the proximal phalanx or the MP joint. Pain with flexion. RESULTS X-rays of the right hand show no obvious signs of fracture or bony abnormalities. IMPRESSION Right hand index finger contusion at the tip of the finger. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. She will take Motrin 600 mg every 6 hours for a week. If she does not improve, she will follow up with me. All questions were answered.

[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 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.

[doctor] hello , mrs . martinez . good to see you today . [patient] hey , dr . gomez . [doctor] hey , dragon , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ? [patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm . [doctor] so you have pain in your distal radius ? [patient] yes . [doctor] how did that happen ? [patient] um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm . [doctor] okay . and did it swell up at all ? or- [patient] it did . it got a ... it had a little bit of swelling . not a lot . [doctor] okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ? [patient] a little bit when i move my wrist . um , no numbness in my hand . [doctor] okay . do you have any past medical history of anything ? [patient] um , yes . allergic , um , l- i have allergies . and so i take flonase . [doctor] okay . and any surgeries in the past ? [patient] yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work- [doctor] okay . [patient] on my rake . [doctor] okay . [patient] yeah . [doctor] i was wondering where you were going to go with that . [patient] yeah . [doctor] okay . great . so , let's take a look at , uh , the x-ray of your arm . hey dragon , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you . [patient] okay . [doctor] does it hurt when i press on your arm here ? [patient] yes . [doctor] okay . how about when i bend your arm ? [patient] yes . [doctor] okay . that's pretty tender , ? [patient] mm-hmm . [doctor] how about when i go backwards like that ? [patient] not as much . [doctor] and how about when i flex like this ? [patient] a little . [doctor] but mostly when i do that type of motion ? [patient] yes . [doctor] okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again . [patient] okay . [doctor] okay , great . hey dragon , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . dragon you can finalize the note . [patient] thank you .

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.

[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 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.

[doctor] hi logan . how are you ? [patient] hey , good to see you . [doctor] it's good to see you as well . [doctor] 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] so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain . [patient] mm-hmm . [doctor] so logan , what happened to your back ? [patient] uh , we were helping my daughter with some heavy equipment and lifted some boxes a little too quickly , and they were a little too heavy . [doctor] okay ... and did you strain your back , did something- [patient] i thought i heard a pop when i moved and i had to lie down for about an hour before it actually relieved the pain . and then it's been a little stiff ever since . and this was- what , so today's tuesday . this was saturday morning . [doctor] okay , all right . [doctor] and is it your lower back , your upper back ? [patient] my lower back . [doctor] your lower back , okay . and what- what have you taken for the pain ? [patient] i took some tylenol , i took some ibuprofen , i used a little bit of icy heat on the spot but it really did n't seem to help . [doctor] okay . and um ... do you have any numbing or tingling in your legs ? [patient] uh ... i felt some tingling in my toes on my right foot until about sunday afternoon . and then that seemed to go away . [doctor] okay , and is there a position that you feel better in ? [patient] uh ... it's really tough to find a comfortable spot sleeping at night . i would- i tend to lie on my right side and that seemed to help a little bit ? [doctor] okay , all right . [doctor] well , um ... so how are you doing otherwise ? i know that , you know , we have some issues to talk- [patient] mm-hmm . [doctor] . about today . were you able to take any vacations over the summer ? [patient] um ... some long weekends , which was great . just kind of- trying to mix it up through the summer . so lots of three day weekends . [doctor] okay , well i'm glad to hear that . [doctor] um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ... [patient] yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar . [patient] and uh ... i-i think i need to go clean for a couple of weeks . but other than that , it was been- it's been pretty good eating . [doctor] okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ? [patient] i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , but it's been pretty good and-and under control for the most part . [doctor] okay , and you're you're taking your medication ? [patient] yes , i am . [doctor] okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ? [patient] uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . not great , but it's been okay . [doctor] okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain . [doctor] have you had any other symptoms , chest pain , nausea or vomiting- [patient] no . [doctor] . fever , chills ? [patient] no . no none whatsoever . [doctor] no . okay . all right , well let me go ahead , i want to do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon ? show me the blood pressure . [doctor] so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your- [patient] mm-hmm . [doctor] . blood pressure go up . let's look at the readings . [doctor] hey dragon ? show me the blood pressure readings . [doctor] yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well . [patient] mm-hmm . [doctor] okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ? [patient] sure . [doctor] and kick against my hands . [doctor] okay , good . all right . [doctor] okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur . [patient] mm-hmm . [doctor] on your heart exam . which you've had in the past . [patient] mm-hmm . [doctor] so that sounds stable to me . [doctor] on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? [patient] mm-hmm . [doctor] hey dragon ? show me the diabetes labs . [doctor] okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? [patient] sure . [doctor] hey dragon ? show me the back x-ray . [doctor] so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- [patient] mm-hmm . [doctor] . the history , okay ? [patient] mm-hmm . [doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . [doctor] so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . [patient] mm-hmm . [doctor] i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- [patient] mm-hmm . [doctor] . and see how you do , okay ? [patient] you got it . [doctor] for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ? [patient] mm-hmm . [doctor] hey dragon ? order a hemoglobin a1c . [doctor] so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day . [patient] mm-hmm . [doctor] does that sound okay ? i think we need to get it under better control . [patient] no that's fine . i agree . [doctor] hey dragon ? order lisinopril 20 mg daily . [doctor] and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ... [patient] mm-hmm . [doctor] i do n't think we need to do any- any further , you know , work up of that at this time , okay ? [patient] mm-hmm . [doctor] do you have any questions logan ? [patient] not at this point . [doctor] okay . all right . [doctor] so the nurse will come in to help you get checked out , okay ? [patient] you got it . [doctor] hey dragon ? finalize the note .

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.

[patient] miss edwards is here for evaluation of facial pain this is a 54 -year-old male [doctor] how're you doing doctor cruz nice to see you today [patient] good to see you mister edwards i'm doctor [doctor] tell me what's been going on yeah so i've got this stabbing shooting pain i've had for a while you know and it it especially right here in my right face right in that cheek bone area it's sometimes it gets super hot i've had it for i think a couple of months now and i went to my family doctor and they said i should come see you [patient] okay great i would like to ask you a little bit more about that [doctor] had in your face do you remember how long that you had it probably for about two or three months just just came on slowly i started noticing it but now it's i have episodes where just shooting stabbing kind of a pain in my right cheek bone right face area [patient] mm-hmm do you have any sensory loss meaning like numbness or tingling in that part of your face [doctor] not that i've noticed no okay do you have any symptoms like this anywhere else on your face including the other side of your face [patient] no it's just on the right side mostly not on the left side just on the right side of my face [doctor] have you noticed any weakness on that side of the face like when you smile or while you're doing other things any weakness there not really i mean i've i've i've tried to you know when i smile my smile seems equal on both sides my eyes i do n't have any weakness there my vision seems to be unchanged but just this stabbing severe pain it's just like excruciating pain that i get sometimes does it happen on its own or there are certain things that trigger it [patient] sometimes if i'm if certain temperatures seem to trigger it sometimes or if it's super where it's cold i get a trigger sometimes [doctor] sometimes certain kind of sensory outside of the wind sometimes that seems to trigger it but that's about it [patient] okay and anything that you've done to to that helps for a little bit when you [doctor] pain excess [patient] you know i've tried ibuprofen and motrin that had really has n't helped it just comes on suddenly and then it's kinda stabbing excruciating pain i've tried rubbing some you know some tiger balm on it that did n't work [doctor] but that's you know so i i went to my family doctor and he said you know i really need to see a neurosurgeon [patient] got it how long do these episodes last these pain [doctor] you know it can last for anywhere from a few minutes to sometimes about an hour but generally generally a few minutes [patient] any history of something like multiple sclerosis or any brain tumors that you know [doctor] no nothing like that alright any other kinda headache symptoms that have anything like you had migraines or anything related to the headaches i mean i get occasional headaches but not really i do n't have a history of migraines but i occasionally get headaches like everybody else i take some tylenol that usually goes away but this is different [patient] how severe is the pain on a scale of one to ten [doctor] when it comes on it's like a ten it's like somebody is stabbing you with an ice pick and but usually you know after a few minutes usually it goes away but sometimes it can last up to an hour great so mister i would like to do a physical exam if that's okay with you [patient] sure [doctor] i would like you to follow my finger here and i see that you're following my finger in in both directions can you show me your teeth [patient] that looks nice and symmetric i'm gon na rub my fingers next to your ear can you hear that [doctor] yep [patient] you can hear it on the other side as well [doctor] yep [patient] okay [doctor] i'm gon na take this cotton tape and run it along the side of your face can you feel that okay [patient] yeah it's a little bit numb on my right side not so much on my left side [doctor] okay alright i'm gon na use this little needle here and i'm gon na poke here and i wan na see if you feel like it's being sharp or dull on that part of your face does that feel different or normal [patient] it feels a little bit dull on my left on my right side my left side it feels sharp [doctor] alright good well i had a chance to look at your mri [patient] okay [doctor] and i looked at your mri and it appears to have small blood vessel that is abutting and perhaps even pinching the trigeminal nerve the trigeminal nerve is nerve that comes from the brainstem that goes out to the face and provides the sensory inflammation from the face and you may have a condition called trigeminal neuralgia [patient] okay [doctor] where the nerve compression causes this kind of shooting electrical pain in the face how do we treat it [patient] well the first line would be to try some medications usually we start with medications that are called gabapentin [doctor] or tegretol these are medications that really help reduce the excitability of the nerve [patient] okay [doctor] most people can get the pain control with that but there are some people where the medications are n't gon na be enough and in that situation we would consider surgery i would n't i would n't recommend that now we usually try the medications first [patient] for considering a surgery to decompress the nerve the root cause of the problem is the compression of the blood vessel against the nerve [doctor] okay so we should be tried which one would you recommend the tegretol or yeah i think we could start with the tegretol to start with i just want to make sure that you understand some of the potential side effects that you can have with this [patient] sure [doctor] it's always a little bit of trial and error to figure out what the right dosing that would work for you but some common side effects can include you know memory loss tingling imbalance some people can actually have like dermatologic [patient] skin reaction to this medication and particularly people who have eustachian descent so that we may do some genetic testing just to make sure that it will be safe for you [doctor] okay sounds good let's do it [patient] okay so i will prescribe that for you and then we will see how that goes and if your pain continues we can talk about different surgical options to treat the pain [doctor] yeah i think i would like to try the tegretol first and if that does n't work then i can come back and so once should i come back and just to kinda check back with you and see if you know if it's had enough time for a fact or not [patient] i think one month would be a great time to follow up [doctor] okay sounds good so if you want to send that prescription over to my pharmacy that would be fine and then why do n't i come back in about a month and we'll go from there [patient] great i'll see you then [doctor] alright

CHIEF COMPLAINT Neck pain HISTORY OF PRESENT ILLNESS Jack Torres is a pleasant 40-year-old male who presents to the clinic today for the evaluation of neck pain. The onset of his pain began 1 week ago after he was involved in a motor vehicle accident. He states that he was hit in the back and experienced whiplash. Following the accident he did not present to the emergency room and he does not recall having any swelling or bruising at the neck. He localizes his pain to the posterior aspect of his neck. His pain level is rated at 7 out of 10. When taking ibuprofen he states his pain improves to 5 out of 10. He finds that neck range of motion exacerbates his pain. Initially after the accident he reports that he experienced a couple of headaches, but he states he has not had any recently. He denies any hearing problems or visual disturbances. SOCIAL HISTORY Patient reports that he played football years ago without any neck issues. REVIEW OF SYSTEMS Eyes: Denies visual disturbances. HENT: Denies hearing loss. Musculoskeletal: Reports neck pain. Neurological: Denies headaches. PHYSICAL EXAM NECK: No swelling noted MSK: Examination of the cervical spine: Positive pain to palpation of the soft tissues of the neck. Shoulders and back are nontender to palpation. Positive pain with flexion, rotation, and lateral bending. Severe pain with extension. RESULTS 3 views of the cervical spine were taken. These reveal no evidence of any fractures or bony abnormalities. ASSESSMENT Neck strain. 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 his x-rays did not reveal any signs of a fracture or bony abnormalities. Treatment options were discussed and conservative treatment has been recommended. He will begin taking Motrin 600 mg every 6 to 8 hours. A prescription for Flexeril 10 mg every 12 hours as needed was also provided. He was advised to be mindful of how he moves his neck and to be conservative to avoid straining his neck. I have also recommended that we obtain an MRI for further evaluation as the patient did not go to the emergency room following his accident. He will also be referred to either physical rehab or a chiropractor pending his MRI results.

[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 .

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.