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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.

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

[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

HISTORY OF PRESENT ILLNESS Wayne Jenkins is a pleasant 43-year-old male who presents to the clinic today for the evaluation of a right foot wound, onset 2 to 3 weeks ago. He was seen by his primary care physician who referred him to our office. His last visit with a podiatrist was 2 years ago, however they moved, and he has been unable to get another podiatrist. He denies any specific injury. The patient purchased a new pair of shoes and was breaking them in prior to traveling. Initially, he did not feel that the shoes were too tight, however a blister formed on his right foot. The patient does have neuropathy and notes this might be why he did not notice the tightness. His blister soon became a wound and he was seen by his PCP. He was placed on a round of antibiotics, which he completed yesterday. He denies any changes to the appearance of the wound. The patient denies pain or drainage. His sock will occasionally stick to his wound, regardless of if he has a Band-Aid covering it. The patient has discontinued the use of these shoes. Occasionally, he has issues with stability, which was a primary purpose of purchasing these shoes. He denies any fever or chills. Regarding his diabetes, his last hemoglobin A1C was 8. REVIEW OF SYSTEMS Constitutional: Denies fever and chills. Skin: Reports right foot wound. Neurological: Reports neuropathy. VITALS Temperature: 98.1. Heart rate: 72. Respiration: 16. Blood pressure: 110/65 mm Hg. PHYSICAL EXAM CV: Palpable bilateral femoral and popliteal pulses. No palpable DP or PT pulses but Doppler signs are present. No evidence of fluid collection. SKIN: On the right foot, there is a 1 x 2 inch circular wound on the dorsal aspect of the lateral right foot that is just proximal to the 5th MTP joint. There is some yellow slough present with minimal granulation tissue. No surrounding erythema or cellulitis. No necrosis. No odor. RESULTS 3 views of the right foot were taken today. These reveal no evidence of osteomyelitis. ASSESSMENT 1. Right foot diabetic ulcer. 2. Diabetes. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. At this time, I have recommended that we obtain an ankle brachial index ABI to determine the blood supply to his foot to see if he can heal this wound. I have also performed a debridement in the office to remove some of the dead tissue. I have prescribed a collagenase ointment to be applied to the wound 1 time daily and instructed him to cover with a dry sterile dressing. He will continue this until we see the wound shrinking and the nice pink tissue is present. I have also recommended that the patient be placed in a surgical shoe to take pressure off the area. I do not think that antibiotics are needed at this time. He may need to see a vascular specialist if the ABI indicates that his blood supply is not optimal for wound healing. Regarding his diabetes, I explained the need for controlling his diabetes and the effects this will have on wound healing. I have recommended a diabetic consultation to discuss diet modifications to bring his hemoglobin A1c to a better level. INSTRUCTIONS The patient will follow up with me in 2 weeks to check on his progress.

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

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

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

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

[doctor] hi michelle what's been going on the medical assistant told me that you injured your knee [patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since [doctor] okay and were you able to ski down the hill or did you have to be taken down by the ski patrol [patient] i had to be taken down by the ski patrol i was unable to bear weight [doctor] okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside [patient] it hurts on the outside but it also feels like it wo n't hold my weight [doctor] okay so it feels like it's gon na buckle [patient] hmmm yes [doctor] okay alright and are you able to bend it [patient] i was immediately after the injury but not really now [doctor] okay and how about straightening it are you able to straighten it at all [patient] somewhat but it really hurts when i try to straighten all the way [doctor] okay alright now do you have any numbing or tingling in your toes [patient] no [doctor] okay and can you feel your toes okay [patient] i think so [doctor] okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do [patient] i chase my two four -year-old [doctor] okay do you have twins [patient] i do [doctor] nice that's great [patient] yeah [doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or [patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids [doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy [patient] yes [doctor] okay and no high blood pressure diabetes anything like that [patient] mm-hmm [doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again [patient] my right knee [doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press [patient] yes [doctor] okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain [patient] ibuprofen [doctor] is that helping [patient] somewhat yes [doctor] okay alright do you want something stronger [patient] no i'm okay [doctor] alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured [patient] hmmm no i not i i would like to get back to the running but currently not that active [doctor] okay alright alright do you have any questions about anything [patient] i think you've explained it well [doctor] okay alright so i'll see you again soon okay [patient] okay thank you [doctor] alright take care bye

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

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

CHIEF COMPLAINT Left shoulder pain. HISTORY OF PRESENT ILLNESS Wayne Taylor is a pleasant 66-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. He denies any specific injury. The patient states he is active and has been renovating his basement. He reports a history of intermittent aches and pains in his left shoulder. He has difficulty reaching for or lifting any objects. He adds that he avoids reaching overhead secondary to the pain. The patient describes his pain as constant and worsening. He notes his pain is unbearable when lying on his left shoulder at night. He denies any numbness or tingling in the bilateral upper extremities. He has been taking 2 Extra Strength Tylenol every 6 to 8 hours, which provides some relief. REVIEW OF SYSTEMS Musculoskeletal: Reports left shoulder pain. Neurological: Denies numbness or tingling in the bilateral upper extremities. VITALS All vital signs are within the normal limits. PHYSICAL EXAM Capillary refill is less than 3 seconds. NEURO: Normal sensation. Sensation is intact to light touch in the left upper extremity. 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 acromioclavicular joints. Good hand grip. RESULTS X-rays of the left shoulder were obtained and are reviewed today. These reveal there are no fractures. ASSESSMENT Left shoulder pain, most likely due to rotator cuff tendinopathy. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that his symptoms are most likely due to rotator cuff tendinopathy. I recommend obtaining an MRI of the left shoulder to further assess the rotator cuff. I will also refer him to formal physical therapy to strengthen his left shoulder for approximately 6 to 8 weeks. The patient was provided with educational materials regarding expectations related to his physical therapy. He may continue to take Tylenol as needed. If his symptoms do not improve with physical therapy, we will consider a steroid injection to the left shoulder. All questions were answered. INSTRUCTIONS The patient will follow up with me after he has completed his course of physical therapy.

[doctor] hey charles i'm using this cool new recording device to help me with my documentation is that okay with you [patient] sure [doctor] awesome how are you doing today [patient] well i could be better you know i moved out in the city [doctor] about two years ago bought this big plot of land [patient] oh [doctor] i love it lots of deer round awesome [patient] you be hunter [doctor] huge hunter i love hunter yeah [patient] i have a refrigerator full of venison at home [doctor] do you [patient] mm-hmm [doctor] you want to carry share sure yeah we can switch [patient] nice but so the thing is i have noticed that for some reason my breathing [doctor] is n't what it used to be [patient] sure [doctor] yeah it's you know i i seem to catch my breath a lot more than i used to and i consider myself to be pretty healthy [patient] you look pretty healthy [doctor] thanks so do you thank you you you're feeling short of breath [patient] yes [doctor] okay is there you know is there any other symptoms that you have with that i get like you know mid shortness of breath suddenly for some reason i'm not quite sure why [patient] hmmm [doctor] eyes they're water does n't make very much sense to me [patient] mm-hmm [doctor] i always think it's allergies [patient] okay [doctor] mostly could be [patient] i have a dog that eyes water like that she always gets eyebugers [doctor] yeah i get eyebugers too [patient] uh [doctor] crazy uh the last time it happened i went to the urgent care and they gave me a nebulizer that helped [patient] they prescribed me an inhaler that i use now when i feel the symptoms coming on [doctor] okay great do you ever notice a rash with any of this [patient] no [doctor] do you have any nausea vomiting [patient] no [doctor] besides when you go out heavy drinking right [patient] i mean i diarrhea quite a bit once i go out [doctor] i understand that [patient] heavy drinking [doctor] yeah do you ever get lip or throat swelling [patient] no [doctor] have you ever had any issues with allergies in the past [patient] no [doctor] hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house [patient] i have noticed them in all three situations [doctor] hmmm [patient] in the house when the cat is n't around and outside as well [doctor] hmmm yeah i'm not a big cat person [patient] no neither [doctor] do you do you have any symptoms now well which is [patient] no [doctor] no no travels and no symptoms right now [patient] mm-hmm [doctor] okay [doctor] okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on your body there is no angioedema which is just swelling of your lips like you mentioned no audible stridor which is a bad noise in your airway when it gets swollen so that's good news if you just want to take a deep breath listening to your lungs on your lungs exam i do appreciate some faint expiratory wheezing bilaterally in all lung fields so i know you had a chest x-ray when you came in i'm looking at that chest x-ray right now and your pulmonary function test and they were both normal so let's talk a little bit about what i think is going on for your first problem you have newly diagnosed allergic asthma so i want you to continue the albuterol inhaler i do n't want you to wait until your symptoms flare up or are bad take it as soon as you start to feel any symptoms at all i'm gon na prescribe something else called singulair ten milligrams you might have seen some commercials for it [patient] hmmm [doctor] you take that once daily and that's gon na help decrease the occurrences of your asthma [patient] hmmm [doctor] i also am gon na proceed with allergy testing have you ever had an allergy test before [patient] no [doctor] okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next week to schedule the skin testing do you have any questions for me [patient] should i come my cats [doctor] yes

CHIEF COMPLAINT Cough. MEDICAL HISTORY Patient reports a history of rheumatoid arthritis. He denies any previous history of lung infections or pneumonia. SOCIAL HISTORY Patient reports he stopped smoking tobacco 7 years ago and has felt better since doing so. He notes that he enjoys biking. FAMILY HISTORY Patient reports his mother has a history of breast cancer, but is doing well. He denies any family history of lung cancer. MEDICATIONS Patient reports taking methotrexate 7.5 mg every week. REVIEW OF SYSTEMS Respiratory: Denies cough or shortness of breath. VITALS Blood Pressure: 124/76 mmHg. Heart Rate: 70 beats per minute. Respiratory Rate: 16 breaths per minute. Oxygen Saturation: 98% on room air. Body Temperature: Afebrile. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear and equal bilaterally. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No clicks, rubs, or murmurs. Pulses are intact in all extremities. Musculoskeletal - Examination: No lower extremity edema. Mild swelling to the 3rd digit knuckles on the bilateral hands, consistent with RA. Integumentary - Examination: Skin is pink, warm, and dry. Capillary refill is brisk. RESULTS CT scan of chest, obtained at an outside facility, is reviewed today and demonstrates a solitary 2 cm nodule in the lateral aspect of the right upper lobe. It appears the nodule is smooth in appearance. No evidence of any type of emphysematous disease is present. ASSESSMENT AND PLAN 1. Right upper lobe lung nodule. - Medical Reasoning: The patient has incidentally found right upper lobe lung nodule visible on his chest CT. It could be a benign nodule, but because of his smoking history, I think it is best that he has it surgically removed. - Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. Surgery will require general anesthesia and will take approximately 1.5 hours. I explained to the patient that his procedure will consist of 3 small incisions being made on the side of his right chest. I will then insert a camera and scope to assist in removing the nodule along with a very small portion of his lung. He was advised that he will be admitted for most likely an overnight stay. He will have a chest tube in until the following day when I remove it at his bedside. All questions were answered. - Medical Treatment: Pulmonary function test ordered today to obtain patient's baseline. PET CT will also be scheduled to determine if the nodule is metabolically active, which can suggest if it is cancerous or inflammatory. Nodule will be removed via video assisted thoracoscopy. 2. Rheumatoid arthritis. - Medical Reasoning: Stable. - Patient Education and Counseling: I encouraged the patient to continue to follow up with his rheumatologist. - Medical Treatment: Continue medication therapy and routine follow up with rheumatologist as previously outlined. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[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 Non-healing ulcer on his right foot. HISTORY OF PRESENT ILLNESS Nicholas Gutierrez is a pleasant 45-year-old male who presents to the clinic today for the evaluation of a non-healing ulcer on his right foot. The patient was referred from his primary care physician. The onset of his pain began 6 weeks ago, after wearing a pair of shoes that were too tight. Today, he describes a burning, stinging, and throbbing sensation. The patient reports a blister on the pad of the plantar aspect of his foot around his heel. He explains that he has been ambulating on the anterior aspect of his foot. He explains that the top part of the skin of the blister detached, which revealed a thick, soft, mushy skin associated with unpleasant smell and yellow drainage. The patient called his primary care physician, who referred him to our office. He was prescribed a 10-day course of antibiotics approximately 6 days ago. He experienced chills and a fever of 99.7 degrees Fahrenheit. The patient denies any nausea or vomiting. He states that when he started the antibiotics, his foot began to feel pretty good. However, he has now noticed that his foot has turned black around the outside of the wound, and he is experiencing cramping in his calf muscle as well. He also reports a burning red streak that was coming up the front part of his ankle along the inside portion of his calf muscle. While palpating his calf, he has noted stiffness in the muscle that is now up to the patella. The patient reports that he has been coughing a lot over the last 2 days. He has experienced shortness of breath with ambulation around the house. He reports that he purchases new diabetic shoes yearly and changes the inserts every 3 to 4 months. The patient is diabetic and has diabetic neuropathy. He explains that his blood sugar has been trending in the 300 to 400's over the last 2 weeks. At one point, he had a blood sugar spike to either 500 or 600. He states that his last hemoglobin A1c was 6.7, which has been his average for approximately 2 years. The patient checks his blood sugar 2 to 3 times per day and rarely has a blood sugar that goes over 200. He explains that he used to be on an insulin pump and had an A1c that at one point was 13. He states that he worked with an endocrinologist to get it down to where it is now. MEDICAL HISTORY The patient reports a history of diabetic neuropathy. SOCIAL HISTORY The patient enjoys hiking. REVIEW OF SYSTEMS Constitutional: Reports subjective fever and chills Respiratory: Reports cough and shortness of breath with ambulation. Gastrointestinal: Denies nausea and vomiting. Musculoskeletal: Reports right foot pain and right calf cramping. Skin: Reports right foot ulcer with yellow foul smelling drainage, and red streaking coming up the front part of his ankle along the inside portion of his calf muscle. VITALS Temperature is slightly elevated. Vitals are otherwise good. PHYSICAL EXAM CV: Edema and pain in calf. Bilateral palpable femoral and papiteal pulses are present. I do not recognize a palpable dorsalis pedis or posterior tibial pulse; however, they are present via Doppler. MSK: Examination of the right foot: The necrotic wound on his heel is present. It is approximately 2 cm x 2 cm. I do recognize the sloughing of the tissue, as well as what looks like cellulitis around the area, and erythema. An odor is present from the wound. I do not appreciate any bony exposure now. No pain to palpation in the effected area. RESULTS 3 views of the right foot were taken today. These reveal no evidence of osteomyelitis or infection. ASSESSMENT Right non-healing diabetic foot ulcer. Diabetes. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed. In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results. INSTRUCTIONS The patient will follow up with me in 7 days to check on his progress.

[doctor] hi michelle what's been going on the medical assistant told me that you injured your knee [patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since [doctor] okay and were you able to ski down the hill or did you have to be taken down by the ski patrol [patient] i had to be taken down by the ski patrol i was unable to bear weight [doctor] okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside [patient] it hurts on the outside but it also feels like it wo n't hold my weight [doctor] okay so it feels like it's gon na buckle [patient] hmmm yes [doctor] okay alright and are you able to bend it [patient] i was immediately after the injury but not really now [doctor] okay and how about straightening it are you able to straighten it at all [patient] somewhat but it really hurts when i try to straighten all the way [doctor] okay alright now do you have any numbing or tingling in your toes [patient] no [doctor] okay and can you feel your toes okay [patient] i think so [doctor] okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do [patient] i chase my two four -year-old [doctor] okay do you have twins [patient] i do [doctor] nice that's great [patient] yeah [doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or [patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids [doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy [patient] yes [doctor] okay and no high blood pressure diabetes anything like that [patient] mm-hmm [doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again [patient] my right knee [doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press [patient] yes [doctor] okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain [patient] ibuprofen [doctor] is that helping [patient] somewhat yes [doctor] okay alright do you want something stronger [patient] no i'm okay [doctor] alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured [patient] hmmm no i not i i would like to get back to the running but currently not that active [doctor] okay alright alright do you have any questions about anything [patient] i think you've explained it well [doctor] okay alright so i'll see you again soon okay [patient] okay thank you [doctor] alright take care bye

CHIEF COMPLAINT Macromastia. HISTORY OF PRESENT ILLNESS Julia Jones is a 25-year-old female who presents for evaluation of macromastia. Ms. Jones reports this is her first visit in regard to a breast reduction and has been interested in getting a breast reduction for approximately 7 years. Currently she has Blue Cross Blue Shield insurance but will be added to her spouse’s insurance plan in 07/2021. Current breast size is a G cup, although she primarily wears a 34 E sports bra for comfort, and desired breast size is a B or C cup. No prior pregnancies, potentially planning on pregnancies in the future, and unsure of breast feeding. The patient endorses back and neck pain since she was in high school. Her back and neck pain has been managed by a chiropractor for a few years. She reports weight loss of 10 pounds over the past few months and would like to lose an additional 20 pounds. She endorses the following symptoms because of her macromastia for 7 years: Chronic upper back pain: Yes. Bra strap grooving in shoulders or indentation on lateral chest wall: Occasionally. Neck pain: Yes. Nipple pain or numbness: Yes. Paresthesia of the hands or arms: Yes. Intertrigo, rash or yeast or other skin problems beneath breasts: Yes, persistent sweating. Stooped posture: Yes. Physical activity limited by breast size: Yes. The patient has undergone the following therapies: Physical therapy: No. Special bras: Yes. Non-narcotic pain medication: No. Narcotic pain medication: No. Her previous breast surgery includes: Previous reconstruction: No. PAST HISTORY Medical Significant for migraine headaches. FAMILY HISTORY Mother with prior history of breast cancer at age 40. SOCIAL HISTORY Tobacco: No prior history. Alcohol: Socially. One glass per week. Drug: No prior history. Occupational and Educational: Currently studying to be a psychologist. CURRENT MEDICATIONS Propranolol for migraine prevention. VITALS BSA 2.65 PHYSICAL EXAM Breasts Inspection reveals asymmetrical breasts with severe ptosis bilaterally. There is no nipple retraction or discharge bilaterally. No breast tenderness, masses, or axillary lymphadenopathy is palpable. ASSESSMENT • Macromastia. Julia Jones is a 25-year-old female with symptomatic macromastia presenting for evaluation of breast reduction. The patient has attempted non-surgical treatments with minimal relief and is an ideal candidate for bilateral reduction mammoplasty. Her minimum required resection based on a BSA of 2.65 with the Schnur scale is 1792 g, which should be attainable. Given her extremely large breasts and the measurements above, there is potential for using a free nipple graft. PLAN An extensive discussion of breast reduction surgery was performed with the patient with consideration of the patient's age, co-morbidities, previous surgical history, body habitus, BMI, and smoking history. Surgical time, immediate recovery course, and longer term recovery course were discussed. Relief of the patient's current symptoms related to macromastia was not guaranteed though is expected to improve. Specific breast size was discussed, also not guaranteed. I explained the expected outcomes of using a free nipple graft such as an insensate nipple and an inability to breast feed. The patient understands that the decision for a free nipple graft will be made intraoperatively based on assessment of nipple perfusion. Risks and benefits of were discussed with the patient The patient understands the above risks, benefits and alternatives to surgery and wishes to proceed with bilateral reduction mammaplasty. The patient will be switching to a different insurance policy in 07/2021. Once we get the new insurance information from the patient, we will submit it to her insurance company. If approved, she will return for preoperative counseling and consent. Return to clinic prior to scheduled surgery date for preoperative counseling and consent.

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

[doctor] hey charles i'm using this cool new recording device to help me with my documentation is that okay with you [patient] sure [doctor] awesome how are you doing today [patient] well i could be better you know i moved out in the city [doctor] about two years ago bought this big plot of land [patient] oh [doctor] i love it lots of deer round awesome [patient] you be hunter [doctor] huge hunter i love hunter yeah [patient] i have a refrigerator full of venison at home [doctor] do you [patient] mm-hmm [doctor] you want to carry share sure yeah we can switch [patient] nice but so the thing is i have noticed that for some reason my breathing [doctor] is n't what it used to be [patient] sure [doctor] yeah it's you know i i seem to catch my breath a lot more than i used to and i consider myself to be pretty healthy [patient] you look pretty healthy [doctor] thanks so do you thank you you you're feeling short of breath [patient] yes [doctor] okay is there you know is there any other symptoms that you have with that i get like you know mid shortness of breath suddenly for some reason i'm not quite sure why [patient] hmmm [doctor] eyes they're water does n't make very much sense to me [patient] mm-hmm [doctor] i always think it's allergies [patient] okay [doctor] mostly could be [patient] i have a dog that eyes water like that she always gets eyebugers [doctor] yeah i get eyebugers too [patient] uh [doctor] crazy uh the last time it happened i went to the urgent care and they gave me a nebulizer that helped [patient] they prescribed me an inhaler that i use now when i feel the symptoms coming on [doctor] okay great do you ever notice a rash with any of this [patient] no [doctor] do you have any nausea vomiting [patient] no [doctor] besides when you go out heavy drinking right [patient] i mean i diarrhea quite a bit once i go out [doctor] i understand that [patient] heavy drinking [doctor] yeah do you ever get lip or throat swelling [patient] no [doctor] have you ever had any issues with allergies in the past [patient] no [doctor] hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house [patient] i have noticed them in all three situations [doctor] hmmm [patient] in the house when the cat is n't around and outside as well [doctor] hmmm yeah i'm not a big cat person [patient] no neither [doctor] do you do you have any symptoms now well which is [patient] no [doctor] no no travels and no symptoms right now [patient] mm-hmm [doctor] okay [doctor] okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on your body there is no angioedema which is just swelling of your lips like you mentioned no audible stridor which is a bad noise in your airway when it gets swollen so that's good news if you just want to take a deep breath listening to your lungs on your lungs exam i do appreciate some faint expiratory wheezing bilaterally in all lung fields so i know you had a chest x-ray when you came in i'm looking at that chest x-ray right now and your pulmonary function test and they were both normal so let's talk a little bit about what i think is going on for your first problem you have newly diagnosed allergic asthma so i want you to continue the albuterol inhaler i do n't want you to wait until your symptoms flare up or are bad take it as soon as you start to feel any symptoms at all i'm gon na prescribe something else called singulair ten milligrams you might have seen some commercials for it [patient] hmmm [doctor] you take that once daily and that's gon na help decrease the occurrences of your asthma [patient] hmmm [doctor] i also am gon na proceed with allergy testing have you ever had an allergy test before [patient] no [doctor] okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next week to schedule the skin testing do you have any questions for me [patient] should i come my cats [doctor] yes

CHIEF COMPLAINT Hepatitis C. SOCIAL HISTORY Patient reports personal history of intravenous drug use over 15 years ago. She is currently smoking 1-2 cigarettes per day, previously 1 to 1.5 packs per day. She also has a history of heavy alcohol use, but now drinks approximately 1 beer per day, more on the weekends. FAMILY HISTORY Patient reports family history significant for hypertension, diabetes, and depression. REVIEW OF SYSTEMS Constitutional: Reports fatigue. All other systems were reviewed and are negative. VITALS Vitals look good today. PHYSICAL EXAM Constitutional - General Appearance: in no apparent distress. Respiratory - Auscultation of Lungs: No wheezes, rales, or rhonchi. Cardiovascular - Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur, unchanged. Gastrointestinal - Examination of Abdomen: No masses or tenderness. No hepatosplenomegaly. - Auscultation: Bowel sounds normal. Musculoskeletal - Examination: No edema. Integumentary - Examination: No signs of jaundice. RESULTS HCV antibody: Positive AST: 39 ALT: Within normal limits Albumin: Within normal limits Bilirubin, total: Within normal limits ASSESSMENT AND PLAN 1. Hepatitis C. - Medical Reasoning: Her recent blood work revealed a positive HCV antibody. She does have a history of intravenous drug use, but she has not used drugs in over 15 years. - Patient Education and Counseling: We discussed the nature of hepatitis C in detail. I advised the patient to have her spouse and children tested for hepatitis C as well. - Medical Treatment: I'm going to order additional labs including a hepatitis C RNA and HCV genotype to confirm the diagnosis, as well as a Fibroscan to assess the severity of the condition. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 3 weeks.

[doctor] okay hi andrea well i [patient] hello [doctor] i understand you're you've come in with some right knee pain can you tell me about it what's going on [patient] it it's not the right knee it's the left knee [doctor] okay the left knee [patient] and it just happens occasionally less than once a day when i'm walking all of a sudden it is kind of like gives out and i think here i'm going to fall but i usually catch myself so lot of times i have to hold a grocery cart and that helps a lot so it comes and goes and it it passes just about as quickly as it comes i do n't know what it is whether i stepped wrong or i just do n't know [doctor] okay well so where does it hurt like in on the inside or the outside or [patient] internally and it it just the whole kneecap fades [doctor] okay well did you hear or feel a pop at any point [patient] no [doctor] okay [patient] like that [doctor] have you ever had any type of injury to that knee i mean did you fall or bump it against something or [patient] no not that i can recall [doctor] okay and have is it painful have you taken anything for for pain [patient] no because it does n't last that long [doctor] okay [patient] it just like i said it just it goes about as fast as i came in [doctor] so is it interfering with your just things you like to do and [patient] hmmm no not really [doctor] so i know you said that you like to do a lot of travel [patient] yeah i've got a trip planned here in the next month or so and we are going down to columbus georgia to a a lion's club function and probably be doing a lot of walking there and they got some line dances planned and i do n't think i will be able to participate in that because of the knee [doctor] is that where you would be kicking your leg out or something [patient] no it's do n't you know what line dancing is like dancing in theories of fairly fast moves but it's mostly sideways motion [doctor] and is and that you think that's when your knee might give out then or just not gon na take the chance [patient] not gon na take the chance [doctor] okay yeah that sounds like a good idea have you thought about even having a a cane just in case or do you think that's does that happen often enough [patient] wrap it i would n't be able to keep track of it so no no pain [doctor] okay okay well so since you're in how about your blood pressure how how is it doing and have you been taking your blood pressures at home like we talked about [patient] yes they are doing fine still about the same [doctor] so [patient] correct that whatever [doctor] so what has it been running [patient] i ca n't really remember it's been several days since i took it but i think it runs around one twenty over seventy somewhere along in there [doctor] okay alright and so what about your medication we have you on some medication for your blood pressure right [patient] yes i take take them regularly at eight thirty in the morning and eight thirty at night [doctor] and what is the medication and the dosage that you are taking [patient] i'm taking a farxiga and amlodipine [doctor] okay [patient] and lisinopril and the hydrochlorothiazide so i i ca n't pronounce that one so but those are all small dosage pills [doctor] that but yeah go ahead [patient] no that was it i just take them regularly eight thirty in the morning eight thirty at night [doctor] yeah well that's good i i know you said you set an alarm on your phone to make sure that you get them taken at the right time so that's really good and how are your blood sugars doing how is your diet doing [patient] my blood sugar has been running a little higher at about one thirty [doctor] is that in the morning when you're fasting [patient] yes [doctor] okay [patient] and i have been told that sometimes the morning blood sugars are higher for some reason but i do n't know i i do n't really worry about it as long as it does n't get up too extremely high so [doctor] and are you taking your metformin [patient] yes yes that's along with the blood pressure medicine morning and night [doctor] okay alright so are you are you eating like late at night or anything like that [patient] no we usually eat by six [doctor] okay okay alright well hopefully we can get you to feeling better okay so i want to do a quick physical exam really check that knee out so your vital signs look good they they look alright your temperature is ninety eight . two your pulse is seventy two respirations are sixteen blood pressure is one twenty two over seventy so that looks fine i'm gon na go ahead and take a listen to your heart and lungs so on your heart exam it's a nice regular rate and rhythm but i appreciate a slight two over six systolic ejection murmur at the left base here on your lung exam your lungs are clear to auscultation bilaterally okay now let's take a quick look at that knee so does it hurt when i press on it [patient] no [doctor] okay can you bend your knee and straighten it out [patient] yes [doctor] okay i'm gon na do some maneuvers and i'm gon na just gon na call out my findings on this okay on your right knee exam no ecchymosis or edema no effusion no pain to palpation of the of the left medial knee is there any decreased range of motion do you feel you feel like you're you're able to fully move that as you should the same as the other knee [patient] yeah [doctor] okay so no decreased range of motion negative varus and valgus test okay and so with your x-rays i reviewed the result of your left knee x-ray which showed no evidence of fracture or bony abnormality so lem me tell you a little bit about my plan so your left knee pain i think you just have some arthritis in that i want to prescribe some meloxicam fifteen milligrams a day we might do some physical therapy for that just to strengthen the muscles around that area and prevent any further problems with that okay and so for your second problem the hypertension so i wan na continue the lisinopril at twenty milligrams a day and order an echocardiogram just to evaluate that heart murmur alright and [patient] okay [doctor] for the diabetes mellitus i wan na order a hemoglobin a1c to see if we need to make any adjustments to your metformin and i'm also gon na order a lipid panel okay do you have any questions [patient] no i do n't think so when will all this take place [doctor] we will get you scheduled for the echocardiogram i will have my nurse come in and we will get that set up okay

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

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

CHIEF COMPLAINT Asthma. MEDICAL HISTORY Patient reports history of asthma. SOCIAL HISTORY The patient denies the use of any type of cigarette or tobacco product, as well as marijuana. Occasionally, she will be at a bar that allows smoking inside, which does bother the patient. She enjoys being outside and hiking. ALLERGIES Denies seasonal allergies. MEDICATIONS Patient reports using an albuterol inhaler, 2 puffs. REVIEW OF SYSTEMS Respiratory: Reports coughing and wheezing. VITALS Blood pressure: 128/82 mm Hg. Respiratory rate: 16 O2 saturation: 99% on room air. PHYSICAL EXAM Neck - General Examination: Neck is supple without lymphadenopathy. Trachea is midline. No carotid bruit. Respiratory - Auscultation of Lungs: Diminished lung sounds throughout with the occasional slight expiratory wheeze, bilaterally. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No ectopic beats. No rubs, murmurs, or gallops. Musculoskeletal - Examination: Strong bilateral radial pulses. No clubbing. Brisk capillary refill. Hematology/Lymphatic/Immunology - Palpation: No enlarged lymph nodes. RESULTS Pulmonary function test obtained today is reviewed and findings are consistent with asthma. ASSESSMENT AND PLAN 1. Moderate intermittent asthma. - Medical Reasoning: The patient's symptoms and results of her PFT are consistent with moderate intermittent asthma. - Patient Education and Counseling: I explained the importance of consistency with her daily inhaler as this will help prevent daily symptoms and the need to use the albuterol inhaler as frequently. My hope is that she has less acute exacerbations as she continues to use her inhaled steroid. - Medical Treatment: Prescribed provided for Flovent 110 mcg 1 puff twice per day. She can continue using her Ventolin inhaler 2 puffs every 4 to 6 hours as needed. I have recommended using her albuterol inhaler 1 to 2 puffs and then monitor her breathing prior to taking an additional 1 to 2 puffs. I am also going to put together an asthma action plan for her so we know what to do based on her symptoms. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 1 month for reevaluation or sooner for worsening symptoms.

[doctor] hi , andrew . how are you ? [patient] hey , good to see you . [doctor] i'm doing well , i'm doing well . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ? [patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse . [doctor] okay . all right . um , now , have you had your covid vaccines ? [patient] yeah , both . [doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ? [patient] none whatsoever . [doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ? [patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me . [doctor] okay . and are you coughing up anything ? [patient] not yet , but i feel like that's next . [doctor] okay . and fevers ? [patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself . [doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ? [patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags . [doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ? [patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working . [doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ? [patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part . [doctor] okay and have they been elevated at all since this episode of your- [patient] no . [doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ? [patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control . [doctor] but you're taking your medication ? [patient] yes . [doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] 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 , your vital signs here in the office look quite good . [patient] mm-hmm . [doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ? [patient] sure . [doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ? [patient] mm-hmm . [doctor] hey , dragon . show me the chest x-ray . [doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ? [patient] good . [doctor] hey , dragon . show me the diabetic labs . [doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight . [patient] mm-hmm . [doctor] i'd like to see that a little bit better , around six or seven , if possible . [patient] mm-hmm . [doctor] um , so let's talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid . [patient] mm-hmm . [doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing . [patient] mm-hmm . [doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ? [patient] you got it . [doctor] for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ... [patient] mm-hmm . [doctor] . refer you to psychotherapy , if you think that that would be helpful . [patient] mm-hmm . [doctor] would you like that ? [patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that . [doctor] okay . all right . [doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily . [patient] mm-hmm . [doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ? [patient] okay , sure . [doctor] hey , dragon . order a hemoglobin a1c . [doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day . [patient] mm-hmm . [doctor] and i'm gon na go ahead and order a lipid panel , okay ? [patient] sure . [doctor] do you need a refill of the lisinopril ? [patient] actually , i do . [doctor] okay . hey , dragon . order lisinopril , 20 milligrams daily . [doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months . [patient] okay . [doctor] let me know if your symptoms worsen and we can talk more about it , okay ? [patient] you got it . [doctor] all right . 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] 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 .

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

[doctor] hi , ms. thompson . i'm dr. moore . how are you ? [patient] hi , dr. moore . [doctor] hi . [patient] i'm doing okay except for my knee . [doctor] all right , hey , dragon , ms. thompson is a 43 year old female here for right knee pain . so tell me what happened with your knee ? [patient] well , i was , um , trying to change a light bulb , and i was up on a ladder and i kinda had a little bit of a stumble and kinda twisted my knee as i was trying to catch my fall . [doctor] okay . and did you injure yourself any place else ? [patient] no , no . it just seems to be the knee . [doctor] all right . and when did this happen ? [patient] it was yesterday . [doctor] all right . and , uh , where does it hurt mostly ? [patient] it hurts like in , in , in the inside of my knee . [doctor] okay . [patient] right here . [doctor] all right . and anything make it better or worse ? [patient] i have been putting ice on it , uh , and i've been taking ibuprofen , but it does n't seem to help much . [doctor] okay . so it sounds like you fell a couple days ago , and you've hurt something inside of your right knee . [patient] mm-hmm . [doctor] and you've been taking a little bit of ice , uh , putting some ice on it , and has n't really helped and some ibuprofen . is that right ? [patient] that's right . yeah . [doctor] okay , let's review your past history for a second . it looks like , uh , do you have any other past medical history ? [patient] uh , afib . [doctor] okay , and are you taking any medications for that ? [patient] yeah , i am . um , begins with a d. [doctor] uh , digoxin ? [patient] that's it . yeah , that's it . [doctor] okay , all right . how about any surgeries in the past ? [patient] i have had a nose job . [doctor] all right . um , let's do your exam , okay ? so is it tender ... where is it mostly tender right now ? [patient] right on the inside of my knee . right here . [doctor] all right , so if i bend your knee forward , does that seem to hurt ? [patient] yes , that hurts . [doctor] all right , how about if i twist it a little bit that way . [patient] that hurts a lot . [doctor] okay , okay . and how about down here ? do you feel me touch you down here ? [patient] yes . [doctor] all right . any other pain down here in your calves ? [patient] no . [doctor] no , okay . so on exam you do have some tenderness over the medial portion of your knee over the medial meniscus area . uh , there is no , uh , there is a little bit of tenderness when i flex your , uh , when i , uh , uh , do some valgus stressing on your , on your leg . um , you have normal sensation . so let's take a look at your x-rays . [patient] okay . [doctor] okay . hey dragon , show me the x-rays . so looking at the x-ray , um , of your left knee , uh , it appears to be there's no fractures there right now . i do n't see any , uh , there's a little bit of , uh , fluid , uh , but there is no , uh , there's no , um , fracture or there's no dislocation . everything else seems to be lined up properly , okay ? [patient] okay . [doctor] so in summary after my exam , uh , looking at your knee , uh , on the x-ray and your exam , you have some tenderness over the medial meniscus , so i think you have probably an acute medial meniscus sprain right now or strain . uh , at this point , my recommendation would be to put you in a knee brace , uh , and we'll go ahead and have you use some crutches temporarily for the next couple days . we'll have you come back in about a week and see how you're doing , and if it's not better , we'll get an mri at that time . [patient] okay . [doctor] i'm going to recommend we give you some motrin , 800 milligrams . uh , you can take it about every six hours , uh , with food . uh , and we'll give you about a two week supply . [patient] okay . [doctor] okay . uh , do you have any questions ? [patient] no , i think i'm good . [doctor] all right . hey , dragon , order the medications and procedures discussed , and finalize the report . okay , come with me and we'll get you checked out .

CHIEF COMPLAINT Psoriatic arthritis management. HISTORY OF PRESENT ILLNESS Judy Gomez is a 61-year-old female who presents to the clinic today for ongoing management of psoriatic arthritis. Ms. Gomez is currently taking methotrexate and prednisone 1 mg daily. She believes methotrexate has been relieving her joint pain. The patient reports she has been doing well since her last visit. She has been able to decrease her prednisone dose to 1 mg daily; however, she took 2 mg for a couple of days due to increased pain in her bilateral feet. The patient states when she received her first COVID-19 vaccine she held her methotrexate and felt "horrible" all week until the next Wednesday when she took it. She felt better by the end of the week. She did not hold methotrexate for her second COVID-19 vaccine. PHYSICAL EXAM Musculoskeletal: Full range of motion. Dystrophy of all the nails of the toes. ASSESSMENT • Psoriatic arthritis. • High risk medication use. PLAN Psoriatic arthritis. Stable on methotrexate and prednisone 1 mg daily. The patient will discontinue prednisone and continue methotrexate. INSTRUCTIONS The patient will follow up in 3 months.

[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 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 , albert . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , albert is a 62-year-old male , with a past medical history significant for depression , type 2 diabetes , and kidney transplant , who is here today for emergency room follow-up . [patient] mm-hmm . [doctor] so , i got a notification that you were in the emergency room , but , but what were you there for ? [patient] well , i , uh , i was n't really , uh , staying on top of my , uh , blood sugar readings , and i felt kinda woozy over the weekend . and i was little concerned , and my wife wanted to take me in and just have me checked out . [doctor] okay . and , and was it , in fact , high ? [patient] yeah , it was . [doctor] okay . did you ... were you admitted to the hospital ? [patient] uh , no . [doctor] okay . all right . and , uh , are you ... did they see a reason , as to why it was elevated ? [patient] uh , yeah . my mother was actually in the hospital the last week. she had a bit of a fall and had to do a hip replacement. she's feeling better now but we have been just grabbing meals at the cafeteria or picking up fast food on our way home and i just really was n't monitoring what i was eating . [doctor] okay . that's sorry to hear . and are you feeling better now ? [patient] uh , actually , when we got home from the , uh , f- from the visit , i felt a lot better . [doctor] okay . and since then , have you been following your diet pretty closely ? [patient] yes . [doctor] okay . 'cause we do n't wan na end up in the hospitaltoo [patient] no . [doctor] all right . um , okay . and , so , before that happened , how are you doing with your diet ? [patient] uh , during the week , i've been fine , 'cause i've been very busy . on the weekends , doing things . you're seeing people . you're having people over . it's , i- not , not as consistent on the weekend . [doctor] okay . all right . um , is there a way that you think that that can improve ? [patient] uh , s- stop eating . [doctor] okay . all right . well , let's talk about your , your kidney transplant . how are- [patient] mm-hmm . [doctor] . you doing ? you're taking immunotherapy meds ? [patient] yes . [doctor] okay . [patient] yeah . i've , i've been pretty diligent about it , following doctor's orders , so it's been , it's been pretty good so far . [doctor] okay . and , and y- the last time i saw that you saw dr. reyes , was about three weeks ago , and everything seemed to be fine . [patient] that's correct . [doctor] your kidney function is good . [patient] yes . [doctor] okay . all right . and in terms of your depression , how are you , how are you doing ? [patient] and it's been about a , a tough , ugh , year-and-a-half or so , but i've been pretty good with it . i , i have my moments , but i- as long as i find some time to relax , at least in the afternoon , then , then it seems to work out okay . [doctor] okay . so , i know that we've kind of talked about holding off on medical therapy- [patient] mm-hmm . [doctor] . 'cause you're on so many other meds . [patient] mm-hmm . [doctor] um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ? [patient] uh , i think i probably wan na shy away from any therapy . my , my wife got me into meditation recently and , and , uh , i , i find that relaxing . so , i think i'd like to continue that , at least for a couple more months and see how it goes . [doctor] okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you- [patient] mm-hmm . [doctor] . checked in . do you have any symptoms , any chest pain or shortness of breath ? [patient] none whatsoever . [doctor] lightheadedness ? dizziness ? [patient] no . [doctor] no ? okay . um , and i just wan na go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey , dragon . show me the vital signs . [doctor] so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be . [patient] mm-hmm . [doctor] so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ? [patient] sure . [doctor] okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past . [patient] mm-hmm . [doctor] your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ? [patient] mm-hmm . [doctor] um , so , let's go ahead . i wan na look at some of your results . okay ? [patient] sure . [doctor] hey , dragon . show me the glucose . [doctor] so , right now , your blood sugar is about 162 . have you eaten before you came in here ? [patient] i did not . [doctor] okay . all right . um , hey , dragon . show me the diabetes labs . [doctor] okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high . [patient] mm-hmm . [doctor] so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated . [patient] mm-hmm . [doctor] so , we'll talk about , you know , how to go ahead and , and fix that . okay ? [doctor] so , let me talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further . [patient] mm-hmm . [doctor] okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , dragon . order a hemoglobin a1c . [doctor] for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ? [patient] mm-hmm . [doctor] okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications . [patient] okay . [doctor] um , and then , he knows to reach out to me if he needs anything . okay ? [patient] you got it . [doctor] all right . well , the nurse will be in soon to check you out . okay ? [patient] perfect . [doctor] hey , dragon . finalize the note .

CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam. The patient states he has been traveling all over the country. He notes it has been a stressful summer and adjusting to everything in the fall. The patient reports a lack of sleep. He has tried melatonin, meditation, and stretching every morning, but nothing has helped. For treatment of his osteoporosis, he is on Fosamax. He denies any issues with his joints. He denies any recent broken bones. Regarding his multiple sclerosis, he last saw the neurologist 6 months ago. He is taking his medication and denies any issues with this. Previously, he experienced right leg weakness, however, this has resolved. He does have some lingering issues with his right knee after previous surgery, but nothing out of the ordinary. The patient denies any chest pain or shortness of breath. REVIEW OF SYSTEMS • Cardiovascular: Denies chest pain or dyspnea. • Respiratory: Denies shortness of breath. • Musculoskeletal: Endorses right knee discomfort. • Neurological: Endorses insomnia. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Musculoskeletal: Weakness in the lower extremities, 4/5 on the right and 3/5 on the left. Reflexes are good. Arthritic changes in the right knee. RESULTS X-ray of the right knee demonstrates some arthritic changes. ASSESSMENT Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam. PLAN Osteoporosis. • Medical Reasoning: The patient is doing well with Fosamax. • Medical Treatment: Continue Fosamax 1 tab per week. Eleven refills were ordered today. Multiple Sclerosis. • Medical Reasoning: The patient is experiencing weakness of the bilateral lower extremities. He has been seeing his neurologist on a consistent basis and has been compliant with medication. • Medical Treatment: He will continue to follow up with his neurologist and comply with his medication regimen. Right knee arthritis. • Medical Reasoning: The patient recently underwent knee surgery. A recent right knee x-ray demonstrated some arthritic changes. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

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

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

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

CHIEF COMPLAINT 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] i know the nurse told you about dax . [patient] mm-hmm [doctor] i'd like to tell dax a little bit about you , okay ? [patient] sure . [doctor] so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ? [patient] um , relatively speaking , okay . it was kind of a , a tough spring with all the pollen and everything and , uh , we dropped my oldest daughter off at college and moved her into her dorm , so little stressful , little chaotic , in the heat of the summer , but so far , so good . [doctor] okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing . [patient] yeah . [doctor] so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year . [patient] yeah , i've been staying on top of the meds , and i have n't had any incidents in a while , so it's , it's been pretty good , and everything's managed and maintained . um , still kind of working with my hypertension . that's been a little bit more of a struggle than anything . [doctor] okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ... [patient] i ... i'm pretty regular with the medications during the business week , but on there's weekends , you know , if i'm on the fly or doing something , sometimes i forget , or i forget to bring it with me . uh , but for the most part , it's been okay . [doctor] okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ? [patient] other than during the heat and the pollen , it's been pretty good . [doctor] okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ? [patient] sometimes i , i regularly , uh , go for a run in the morning . that's my workout , and sometimes if it's , uh , relatively humid , i'll struggle a little bit , and i might feel a little bit of pounding in my chest . it usually goes away , but , uh , again , for the most part , it's been pretty good . [doctor] okay , so you also have some shortness of breath with with exertion . [patient] correct . correct . [doctor] all right , and how far are you running ? [patient] uh , like 4 to 5 miles a day . [doctor] okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure . [patient] mm-hmm . [doctor] hey , dragon , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , dragon , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it has in the past , so continue on the current medication . [patient] mm-hmm . [doctor] all right , so i'm just gon na listen to your heart and lungs and check you out , okay ? [patient] you got it . [doctor] okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today . [patient] mm-hmm . [doctor] and in reviewing the results , it looks like your ekg is completely normal , so that's good . [patient] good . [doctor] so i'm not too concerned about that , that chest pounding . hey , dragon , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my assessment and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well- [patient] mm-hmm . [doctor] . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ? [patient] uh , actually , i do need a refill . [doctor] okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow up with the surgeon anymore . and then for your last problem , your hypertension . [patient] mm-hmm . [doctor] you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , dragon , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ? [patient] perfect . [doctor] all right . good to see you . [patient] same here . [doctor] hey , dragon , finalize the note . the nurse will be in . [patient] thank you .

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

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

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

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

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

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

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

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.

[doctor] hi , andrew . how are you ? [patient] hey , good to see you . [doctor] i'm doing well , i'm doing well . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ? [patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse . [doctor] okay . all right . um , now , have you had your covid vaccines ? [patient] yeah , both . [doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ? [patient] none whatsoever . [doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ? [patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me . [doctor] okay . and are you coughing up anything ? [patient] not yet , but i feel like that's next . [doctor] okay . and fevers ? [patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself . [doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ? [patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags . [doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ? [patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working . [doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ? [patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part . [doctor] okay and have they been elevated at all since this episode of your- [patient] no . [doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ? [patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control . [doctor] but you're taking your medication ? [patient] yes . [doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] 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 , your vital signs here in the office look quite good . [patient] mm-hmm . [doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ? [patient] sure . [doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ? [patient] mm-hmm . [doctor] hey , dragon . show me the chest x-ray . [doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ? [patient] good . [doctor] hey , dragon . show me the diabetic labs . [doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight . [patient] mm-hmm . [doctor] i'd like to see that a little bit better , around six or seven , if possible . [patient] mm-hmm . [doctor] um , so let's talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid . [patient] mm-hmm . [doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing . [patient] mm-hmm . [doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ? [patient] you got it . [doctor] for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ... [patient] mm-hmm . [doctor] . refer you to psychotherapy , if you think that that would be helpful . [patient] mm-hmm . [doctor] would you like that ? [patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that . [doctor] okay . all right . [doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily . [patient] mm-hmm . [doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ? [patient] okay , sure . [doctor] hey , dragon . order a hemoglobin a1c . [doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day . [patient] mm-hmm . [doctor] and i'm gon na go ahead and order a lipid panel , okay ? [patient] sure . [doctor] do you need a refill of the lisinopril ? [patient] actually , i do . [doctor] okay . hey , dragon . order lisinopril , 20 milligrams daily . [doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months . [patient] okay . [doctor] let me know if your symptoms worsen and we can talk more about it , okay ? [patient] you got it . [doctor] all right . hey , dragon . finalize the note .

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

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

CHIEF COMPLAINT Right ankle injury. HISTORY OF PRESENT ILLNESS Jerry Cook is a 45-year-old male who presents today with a right ankle injury. The patient sustained an injury to the right ankle while playing basketball with his son. He reports he landed awkwardly and twisted his right ankle after jumping to make a layup. His pain is primarily located along the lateral aspect of the right ankle. He notes bruising and swelling. The patient is able to weight-bear while standing. He experiences pain and feelings of instability within the ankle while ambulating and is concerned for further injury. SOCIAL HISTORY The patient works from home and plans to coach his son’s basketball team in 04/2022. He enjoys working out and reports he recently resumed engaging in a consistent gym routine. REVIEW OF SYSTEMS Musculoskeletal: Reports right ankle pain and instability. Skin: Reports right ankle bruising and swelling. PHYSICAL EXAM CV: Brisk capillary refill. SKIN: No epidermolysis. Intact. MSK: Examination of the right ankle: Exquisite tenderness laterally. Mild tenderness over the medial deltoid region. Swelling on the lateral side of the ankle. No horrible malalignment. RESULTS X-rays, including AP, lateral, and oblique views of the right ankle, were obtained in the office and reviewed today. These demonstrate a displaced lateral malleolus at the Weber C level. There is no evidence of medial or posterior malleolar fractures. ASSESSMENT Right lateral malleolar fracture. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding treatment options. Recommendation was made for an open reduction internal fixation of the right ankle. We discussed the risks and benefits of the procedure as well as the postoperative recovery period following surgery. I advised that it will be 3 months before he can resume his exercise routine. In the meantime, I will prescribe meloxicam to reduce swelling. I recommended he ice and elevate the ankle as well. He will be given crutches to assist with ambulation. The patient understands and agrees with the recommended medical treatment plan.

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

CHIEF COMPLAINT 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.

[doctor] hey philip good to see you today so take a look here at my notes i see you're coming in for some right knee pain and you have a past medical history of hypertension and we will take a look at that so can you tell me what happened to your knee [patient] yeah i was you know i was just doing some work on my property and i i accidentally slipped and fell down and i just still having some knee issues [doctor] okay well that that's not good do you [patient] no [doctor] what part of your knee would you say hurts [patient] i would just say you know the it it you know it basically when i when i'm flexing my knee when i'm moving it up and down and i put pressure on it [doctor] alright did you hear a pop or anything like that [patient] i did feel something pop yes [doctor] okay and did it was it swollen afterwards or is it looks a little bit swollen right now [patient] yeah little bit swollen yeah [doctor] okay so so far have you taken anything for the pain [patient] just taking some ibuprofen just for some swelling [doctor] okay that's it what would you say your pain score is a out of ten with ten being the worst pain you ever felt [patient] i would say that when i'm stationary i do n't really feel a lot of pain but if i start doing some mobility i would say probably a four five [doctor] about a four okay and how long ago did you say this was is this happened this injury [patient] it's been a week now [doctor] a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly [patient] yes i have [doctor] okay so you might have a little white coat syndrome i know some of my patients definitely do have that so what about your diet i know we talked a little bit before about you reducing your sodium intake to about twenty three hundred milligrams per per day i know you were during the pandemic your diet got out of little bit out of control so how have you been doing how have you been doing with that [patient] i definitely need some help there i have not have not made some some changes [doctor] okay yeah we definitely need to get you to lower that salt intake get your diet a little bit better because the hope is to get you off that medication and get your blood pressure to a manageable level okay so we yeah we definitely can talk about that alright so lem me take a look at your knee i'll do a quick physical exam on you and before i do just want to make sure you're not having any chest pain today [patient] no [doctor] are you any belly pain [patient] no [doctor] no shortness of breath just wan na make sure [patient] no [doctor] okay so i'm just gon na listen to your lungs here your lungs are clear bilaterally i do n't hear any wheezes or crackles listen to your heart so on your heart exam i do still hear that grade two out of six systolic ejection murmur and you already had that and so we we knew about that already so lem me look at your knee here so when i press here on the inside of your knee does that hurt [patient] a little bit [doctor] little bit how about when i press on the outs the outside gon na press on the outside is that painful [patient] no [doctor] no alright so i'm gon na have you flex your knee is that painful [patient] yeah that's uncomfortable [doctor] that's uncomfortable and extend it so that's painful [patient] yeah yes [doctor] okay so on your knee exam i i see that you do have pain to palpation of the medial aspect of your right knee you have some pain with flexion extension i also identify some edema around the knee and some effusion you have a little bit of fluid in there as well so prior to coming in we did do an x-ray of that right knee and luckily you did n't break anything so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you have what we call a mcl strain so a medial collateral ligament strain so when you fell i think you twisted a little bit and so it irritated you strained that that ligament there so for that what we can do for you first i'm gon na prescribe you some ibuprofen eight hundred milligrams and you can take that twice a day and that's gon na help you with that swelling and that pain that you currently do have i'm also gon na put you in a a knee brace just to try and support those muscles to allow it to heal and then i want you to ice the knee you can do that for twenty minutes at a time for three to four times a day that should also help with the the swelling of your knee for your hypertension now i'm gon na keep you on that twenty of lisinopril okay because you are taking it and you you're doing pretty good with it i also want to get you a referral to nutrition just to try to help you with that diet you know because right now you are your diet is little bit out of control so we just need to rain you in a little bit and hopefully you know with their help we can eventually get you off that lisinopril alright so do you have any questions for me [patient] do i need to elevate my leg or stay off my leg or [doctor] yeah i would yeah you can elevate your leg stay off your stay off your leg you know if you have any kids have them work out in the yard instead of you just to to for a couple of weeks it's a good thing if you want to do that [patient] tell him this doctor's order [doctor] tell definitely tell him his doctor tell him i said it [patient] alright do you have any other questions no that's it i appreciate you seeing me [doctor] alright so my nurse will be in with the those orders and we will see you next time

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

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

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

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

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

[doctor] i know the nurse told you about dax . [patient] mm-hmm [doctor] i'd like to tell dax a little bit about you , okay ? [patient] sure . [doctor] so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ? [patient] um , relatively speaking , okay . it was kind of a , a tough spring with all the pollen and everything and , uh , we dropped my oldest daughter off at college and moved her into her dorm , so little stressful , little chaotic , in the heat of the summer , but so far , so good . [doctor] okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing . [patient] yeah . [doctor] so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year . [patient] yeah , i've been staying on top of the meds , and i have n't had any incidents in a while , so it's , it's been pretty good , and everything's managed and maintained . um , still kind of working with my hypertension . that's been a little bit more of a struggle than anything . [doctor] okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ... [patient] i ... i'm pretty regular with the medications during the business week , but on there's weekends , you know , if i'm on the fly or doing something , sometimes i forget , or i forget to bring it with me . uh , but for the most part , it's been okay . [doctor] okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ? [patient] other than during the heat and the pollen , it's been pretty good . [doctor] okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ? [patient] sometimes i , i regularly , uh , go for a run in the morning . that's my workout , and sometimes if it's , uh , relatively humid , i'll struggle a little bit , and i might feel a little bit of pounding in my chest . it usually goes away , but , uh , again , for the most part , it's been pretty good . [doctor] okay , so you also have some shortness of breath with with exertion . [patient] correct . correct . [doctor] all right , and how far are you running ? [patient] uh , like 4 to 5 miles a day . [doctor] okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure . [patient] mm-hmm . [doctor] hey , dragon , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , dragon , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it has in the past , so continue on the current medication . [patient] mm-hmm . [doctor] all right , so i'm just gon na listen to your heart and lungs and check you out , okay ? [patient] you got it . [doctor] okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today . [patient] mm-hmm . [doctor] and in reviewing the results , it looks like your ekg is completely normal , so that's good . [patient] good . [doctor] so i'm not too concerned about that , that chest pounding . hey , dragon , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my assessment and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well- [patient] mm-hmm . [doctor] . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ? [patient] uh , actually , i do need a refill . [doctor] okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow up with the surgeon anymore . and then for your last problem , your hypertension . [patient] mm-hmm . [doctor] you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , dragon , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ? [patient] perfect . [doctor] all right . good to see you . [patient] same here . [doctor] hey , dragon , finalize the note . the nurse will be in . [patient] thank you .

CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam. The patient states he has been traveling all over the country. He notes it has been a stressful summer and adjusting to everything in the fall. The patient reports a lack of sleep. He has tried melatonin, meditation, and stretching every morning, but nothing has helped. For treatment of his osteoporosis, he is on Fosamax. He denies any issues with his joints. He denies any recent broken bones. Regarding his multiple sclerosis, he last saw the neurologist 6 months ago. He is taking his medication and denies any issues with this. Previously, he experienced right leg weakness, however, this has resolved. He does have some lingering issues with his right knee after previous surgery, but nothing out of the ordinary. The patient denies any chest pain or shortness of breath. REVIEW OF SYSTEMS • Cardiovascular: Denies chest pain or dyspnea. • Respiratory: Denies shortness of breath. • Musculoskeletal: Endorses right knee discomfort. • Neurological: Endorses insomnia. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Musculoskeletal: Weakness in the lower extremities, 4/5 on the right and 3/5 on the left. Reflexes are good. Arthritic changes in the right knee. RESULTS X-ray of the right knee demonstrates some arthritic changes. ASSESSMENT Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam. PLAN Osteoporosis. • Medical Reasoning: The patient is doing well with Fosamax. • Medical Treatment: Continue Fosamax 1 tab per week. Eleven refills were ordered today. Multiple Sclerosis. • Medical Reasoning: The patient is experiencing weakness of the bilateral lower extremities. He has been seeing his neurologist on a consistent basis and has been compliant with medication. • Medical Treatment: He will continue to follow up with his neurologist and comply with his medication regimen. Right knee arthritis. • Medical Reasoning: The patient recently underwent knee surgery. A recent right knee x-ray demonstrated some arthritic changes. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened [patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april and we were at the courts plan and i went up for a shot and he's far more aggressive than with me than he is with you know his peers i guess he could say and so he he found me while i was going for a lap and then when i came down i kind of landed awkwardly and i kind of like rolled and twisted my my ankle so now it's it's hurting a bit like kind of on the outside you can you can even see it's it's bruised up and a bit swollen [doctor] yeah [patient] and yeah i've been having trouble walking and it just does n't feel solid really stable which is a problem i i recently got back into working out and i had been in a really good rhythm going to the gym [doctor] okay [patient] and i do n't want to disrupt that moments on because it took a lot for me to get back to a good place so [doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way [patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys [doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad [patient] yeah yes [doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too [patient] yeah a little bit [doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all [patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid [doctor] sure so it does n't quite feel stable [patient] yeah [doctor] okay okay i gotcha so i know you had an x-ray as you came in today and so i'm just looking at this x-ray here i'll show you on the screen right here i can turn my monitor towards you this is an ap lateral oblique and this is your right ankle so what we're looking at is a displaced lateral malleolus at the weber c level there's no evidence of medial or posterior malleolar fractures but this is a fracture on the lateral side of your ankle now based on the position it's a bit unstable that's why you're feeling some of that that instability when you're walking so for your diagnosis what i'm gon na put down is a lateral malleolar fracture and what i would recommend for that since it is in the location that it is is you're probably unfortunately gon na need surgery we're gon na wan na get that healed what that includes is putting some plate and some screws in and you're gon na be out for a little bit so i know you've been trying to work out and and you wan na get back on the court but but you may have to have to sit out for a little bit we'll get you some crutches [patient] how long it's a little bit because i'm also i i forgot to say i'm also i did volunteer to coach [doctor] great [patient] starting in april so [doctor] alright well [patient] how long [doctor] yeah you you're probably gon na be out for about three months but continue the coaching go ahead and and let's get you back out there we'll get you some crutches and and hopefully you can kinda you know get back on the court start coaching and then within that three months we'll we'll get you back out doing some exercise again [patient] okay [doctor] alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly [patient] yeah i i work from home so that that should n't be a problem it's just everything else i do n't know who is gon na walk my dogs and and do all this stuff that's rest of my family refuses to walk my dog so we'll figure it out [doctor] yeah i i'm a dog walker as well so alright sorry for the bad news but let's get you healed up so that we can get you back out doing everything you need to do [patient] alright thank you doctor [doctor] alright thanks

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

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

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

[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 Shortness of breath. HISTORY OF PRESENT ILLNESS Charles Sullivan is a pleasant 45-year-old male who presents to the clinic today for the evaluation of shortness of breath. The onset of his symptoms began 2 years ago. He has noticed that his breathing is not what it used to be. He describes an increased need to catch his breath. The patient also reports he gets “mid-shortness of breath” without reason. He has been seen at an urgent care where he received a nebulizer treatment and was prescribed an inhaler, which he uses when his symptoms are present. The patient states his symptoms are aggravated by living with a cat in his house and are present even when the cat is not around or is outside. He has experienced epiphora with rheum present that he attributes to allergies. He has had diarrhea after consuming large amounts of alcohol. He denies any symptoms at this time including shortness of breath, rash, nausea, vomiting, and lip or throat swelling. The patient denies any previous issues with allergies. He enjoys hunting. VITALS Oxygen Saturation: Normal on room air. PHYSICAL EXAM CONSTITUTIONAL: In no apparent distress. HEAD: No angioedema. RESPIRATORY: No audible stridor. I do appreciate some faint expiratory wheezing bilaterally in all lung fields. SKIN: No rash. RESULTS A chest x-ray, obtained and reviewed today is normal. Pulmonary function test, obtained and reviewed today is normal. ASSESSMENT Newly diagnosed allergic asthma. PLAN After reviewing the patient's examination, radiographic findings, and pulmonary function test results today, I have had a lengthy discussion with him regarding his current symptoms. He will continue to use the albuterol inhaler; however, he should limit its use to when he is experiencing a severe flare-up of symptoms. I advised he should take it as soon as he starts to feel any symptoms at all. I have also prescribed the patient Singulair 10 mg to be taken once daily. This should help to decrease the occurrences of his asthma. I have also recommended we proceed with an allergy skin test to target what his triggers are in the hope that we can avoid any other management. If we unable to determine his allergens, then we may consider further testing or immunotherapy. INSTRUCTIONS The patient will follow up with me in 1 week for skin testing.

[doctor] okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right [patient] yes [doctor] so can you tell me about that how are you doing [patient] well i've been doing okay but i've had this wound on my right foot for a couple of weeks and it's not getting better i saw my pcp and they referred me to you i i used to see a podiatrist and a couple of years ago but they moved and i was n't able to get another one [doctor] okay and how long have you had the wound [patient] about two to three weeks [doctor] okay have you had any kind of trauma to that foot [patient] no i bought a new pair of shoes to travel with and the neuropathy i guess i did n't feel that they were too tight at first it was just a blister but it looked a lot worse now i've been putting a band-aid on it and [doctor] okay and so did your doctor put you on any antibiotics when they they saw your foot [patient] yes i finished the course yesterday the wound looked about the same though [doctor] okay now does it hurt [patient] no i ca n't feel it [doctor] okay now have you had any other symptoms like fever chills drainage from the wound or anything along those lines [patient] no but when i take my sock off sometimes it sticks to the wound even when i put a band-aid on [doctor] okay well are you still wearing those same shoes that cause the problem [patient] no i'm upset [doctor] i'm so upset too i love those shoes [patient] no i'm so upset i i love those shoes [doctor] okay so what kind of shoes are they [patient] they're hoka's [doctor] ah so where did you get them [patient] i got them at rei couple of years ago [doctor] they're pretty good about helping you to fit your fit you in a shoe are n't they [patient] yeah [doctor] so what do you like about them [patient] they are comfortable they are easy to take on and off and they provide good stability [doctor] that's good so you've had some issues with stability sometimes or [patient] yes [doctor] okay okay well another question i want to ask you is how is your diabetes doing [patient] i do n't think it's too bad my last hgb a1c was a little over eight [doctor] okay alright well let me just do a quick physical exam okay for vital signs your temperature is ninety eight . one your vital signs look good your heart rate is seventy two respirations sixteen blood pressure is one ten over sixty five okay so on your foot exam let's see there is a one by two inch circular wound on the dorsal aspect of the lateral right foot it is just proximal to the right fifth to the fifth mtp joint and there is some yellow slough present with minimal granulation tissue there's no surrounding erythema or cellulitis and there's no evidence of fluid collection there's no necrosis there is no odor i do not appreciate any bony exposure on on vascular exam there are palpable bilateral femoral and popliteal pulses there are no palpable dp or pt pulses but doppler signs are present okay so does this hurt when i touch it here [patient] no it's okay [doctor] okay alright so i've reviewed the results your right foot x-ray that we did before you i came in the room and this shows no evidence of osteomyelitis which means there is no evidence of bone infection so that's really good so let me tell you a little about my assessment and plan for you so for your first problem your diabetic foot ulcer so i want to order an ankle brachial index abi to determine the blood supply to your foot to see if you can heal this wound i'm also gon na perform a debridement here in the office to take off some of the dead tissue and then next i'm going to prescribe a collagenase ointment to be applied to the wound once daily and then cover with a dry sterile dressing now we will continue this until we see the wound shrinking and a nice pink tissue is present and i want you to wear a surgical shoe to take pressure off of the area okay so i do n't think any more antibiotics are needed at this time and i want to see you again in two weeks so we may need to refer you to a vascular specialist if the abi indicates your blood supply is not optimal for wound healing okay [patient] okay [doctor] okay so for your diabetes it's gon na be very important to get your diabetes under control in order to get the wound to heal so we might even go ahead and get a diabetic consult so that we can go over some some maybe some ways you can modify your diet without a being too much but maybe that can bring down your hemoglobin a1c into a little bit better level okay [patient] okay [doctor] alright do you have any other questions [patient] no [doctor] okay

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

[doctor] hi jacqueline how are you doing today [patient] i'm doing okay i'm just really anxious about my recent blood work that my pcp did and said that i have hepatitis c i'm just really surprised because i've been feeling fine [doctor] okay so were you ever told in the past that you have hepatitis c [patient] no never [doctor] okay and do do you have any history like iv drug use known that you know or do you have any known to have any like hepatitis c positive partners [patient] i mean like years ago i used to party a lot and even use iv drugs but i've been clean for over fifteen years now [doctor] okay well very good you know congratulations on that that's that's a great great achievement so tell me though how about alcohol use [patient] i used to drink a lot a lot more alcohol now i probably would say i drink about a beer a day [doctor] okay [patient] and maybe slightly more on the weekends but nothing like how i used to [doctor] okay alright how about smoking have you ever smoked [patient] i do smoke i'm down to one to two cigarettes a day it's just really been tough to just get rid of those two but i've cut down a lot i used to i was up to one point or a pack and a half a day [doctor] wow okay alright so yeah you you definitely have decreased that so that's again good for you on that one so hopefully you keep you keep that up [patient] thing [doctor] so tell me do you have any other medication conditions [patient] do i do i no otherwise i'm i'm feel pretty good i had my physical there was nothing else the the only thing i was telling my pcp is i do feel like tend to be really tired at the end of the day after working but otherwise i've been good [doctor] okay and and has work been not hard lately you've been busy it sounds like [patient] i know i have been busy but not really much more than usual [doctor] okay [patient] so that's why i was kind of marking because i mean i used to you know be able and be fine but i just lately have been feeling like i'm getting enough sleep but i still get very tired at the end of the day [doctor] okay alright well i hope you're not working too much and then you'll able to at least find some time with the family [patient] yeah i'm i yeah i tend to be a workaholic but yes i i am working on that [doctor] okay well i hope kids are doing okay [patient] they are thank you [doctor] okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or [patient] yeah all of all of the above [doctor] okay [patient] hypertension diabetes and also depression [doctor] okay and depression okay alright well let's go ahead and do a quick physical exam on you here i reviewed your vitals and everything there looks good so that's good and now on general appearance you appear in no distress and no jaundice on skin exam let me go ahead and listen to your heart here great on your heart exam you have a nice regular rate and rhythm with a two out of six six systolic murmur appreciate appreciated that's that has n't changed from last year so we will just continue to monitor that monitor that as well okay [patient] okay [doctor] alright now let me listen to your lungs here very good so your your lungs are clear with no wheezes rales or rhonchi and let me go ahead and listen to your abdomen great your bowel sounds are present your abdomen is soft with no hepatospleno splenomegaly ca n't talk to appreciated so let me now check your musculoskeletal exam here great i i did n't see any gait disturbance and no edema so that's great so jacqueline i did review the results of your recent blood blood work and your hcv antibody test was positive and your liver panel that was done showing an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so what that all means and let me go ahead and tell you about my assessment and plan here for your first problem of hepatitis c your initial labs are consistent with hepatitis c so based on the the once i just discussed with you there now hepatitis c is a viral infection that affects the liver so you most likely may have had it for years now so the next step that i would like to do is to confirm the diagnosis with some additional blood work that includes checking the hep c rna and also the hcv genotype okay now i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and i'm gon na do this by ordering a special ultrasound and with this information i'm gon na be able to know how to proceed as far as treatment [patient] okay [doctor] alright now i know that was a lot of information do you have any questions for me [patient] yeah so should i be worried about my wife and my kids should they be tested as well [doctor] yes so we can start with the same screening that you have had for you for all of them first okay [patient] okay alright so i'll make sure i'll have them set up an appointment with our our family doctor [doctor] okay great so if you do n't have any other questions i'm gon na have the nurse check you out and get all that scheduled and i'm gon na see you in about three weeks [patient] alright perfect [doctor] alright [patient] thank you [doctor] take care jacqueline [patient] okay bye [doctor] bye

CHIEF COMPLAINT Renal screening tests. HISTORY OF PRESENT ILLNESS Katherine Lopez is a 22-month-old female, born at 34 weeks +3 days gestation, diagnosed with the rare Smith-Magenis syndrome and associated global developmental delays. She was referred to nephrology by genetics who recommended renal screening tests. At birth, the patient weighed 4 pounds 8 ounces, exhibited difficulties during eating where she would stop breathing, and challenges regulating her body temperature; determined to be typical issues associated with premature birth. The patient has seen many specialists, including GI for severe reflux, a dietitian who recommended discontinuing consumption of cow’s milk, and a neurologist who diagnosed her with Smith-Magenis syndrome. Additionally, she has been seen by a geneticist, orthopedist, ophthalmologist, and audiologist. The patient is not ambulatory, did not sit up unassisted until 1 years old, and is currently crawling and attempting to take steps. She will be starting speech therapy in the next few weeks, and currently she is in occupational, feeding, and physical therapy. The geneticist informed the patient's mother that patients with Smith-Magenis syndrome usually have kidney issues where “the kidneys fuse into one” and issues with their legs. The patient has approximately 8 to 10 wet diapers in a 24-hour period. Her mother notes that she is doing better with drinking fluids and she urinates “a lot”. The patient drinks Ripple Pea Protein milk instead of cow’s milk, water and water mixed with a small amount of juice. Her twin sister is approximately the same size, and their weight is essentially the same, she is healthy, and the mom denies any known health concerns or diagnoses. The mom states that Katherine is shorter and seems chubbier related to her syndrome. She also has a 9-year-old brother who is diagnosed with autism. BIRTH HISTORY Twin gestation. Birth weight 4 pounds 8 ounces. PAST HISTORY Medical Smith-Magenis syndrome. SOCIAL HISTORY Patient accompanied to appointment by her mother. Sibling: 9-year-old brother and twin sister. FAMILY HISTORY Brother: 9 years old, positive for autism. Twin sister: absence of Smith-Magenis syndrome, no known health conditions. No known family history of genetic conditions, kidney failure, dialysis, or kidney transplant. PHYSICAL EXAM Constitutional Well-nourished female, slightly fussy when examined. Eyes Presences of microphthalmia. Genitourinary Normal external female genitalia. Musculoskeletal Extremities: Presence of mild hypotonia of lower extremities and the arms. ASSESSMENT • Smith-Magenis syndrome. Katherine is a 22-month-old former 34+3-week-old twin with Smith-Magenis syndrome. Several organ systems can be affected by this chromosomal deletion syndrome and congenital anomalies of the kidney and urinary tract have been reported in the literature. PLAN We will obtain a kidney ultrasound screening today. If there are abnormalities on the kidney ultrasound, we will determine the next steps and future follow-up. The family lives in Dallas, Georgia, so her follow-up should be at the Town Center location. INSTRUCTIONS Complete ultrasound today. I will call patient with results and possible next steps.

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

[doctor] next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri . [doctor] hello , how are you doing today ? [patient_guest] we're okay , thank you . [doctor] that's good to hear . so , how many days has randy been feeling sick ? [patient_guest] well , i would say it started around supper time last night . [doctor] last night , okay , and what's been going on ? [patient_guest] well , he started to get a runny nose . [doctor] okay , and is he stuffy too ? [patient_guest] yeah . yeah . [doctor] okay , and have you noticed , is his mucous clear right now ? [patient_guest] it is , it is right now , yes . [doctor] okay . and , does he also have a cough ? [patient_guest] yes , but it's not barky . [doctor] and does he act like he has a sore throat or is he pulling on his ears ? [patient_guest] well , i know he's been pulling on his ears , yeah . [doctor] okay . [patient_guest] you know , he also , he's also been going crazy rubbing at his nose too . [doctor] okay . and , any fever you've noticed ? [patient_guest] i checked his rectal temperature and it was 100.3 . [doctor] okay . so , a little bit of a low-grade fever there , definitely . and , how was his appetite ? did he eat last night ? [patient_guest] yes , he did . yeah . [doctor] and how about this morning ? did he eat his breakfast ? [patient_guest] uh , this morning he ate about seven ounces from the bottle . [doctor] okay . [patient_guest] and then he got another bottle , and he barely ate that . um , i offered him cereal and he would n't eat that either . [doctor] okay . [patient_guest] so , he varies i guess . [doctor] how is his energy ? does he seem like he wants to take more naps , or does he have pretty good energy ? [patient_guest] mmm , it seems like he's irritable . [doctor] irritable because he is n't feeling good ? [patient_guest] yeah . he is energetic , but it seems like he ca n't go to sleep , like , he's fighting it really hard . [doctor] okay , and just for the chart , is there anyone , anybody else exposed to him who has been sick ? [patient_guest] yes , his older sister's been sick . [doctor] thank you . [patient_guest] we also had a play date with my nephew , who i learned later had a sinus infection . [doctor] and what medication have you tried for him ? anything at all ? [patient_guest] um , i've been doing the saline mist in his nose . [doctor] good , good . that's a good choice . [patient_guest] i did give him tylenol really early this morning because he was warm when i took the sleeper off of him , and we had the ac on in the house , but his whole body was sweating . [doctor] i see . and , any other medications ? [patient_guest] we did put some baby vick's on his feet last night to try and help him breathe . and , i also used the humidifier . [doctor] okay . that's good . [patient_guest] okay . okay . [doctor] so , there was another thing i wanted to bring up since we're here . it appears that his cradle cap has gotten a little worse . what are you using on it ? [patient_guest] i've been using the cradle cap brush , and then i use regular aveno shampoo . [doctor] is it a dandruff shampoo ? [patient_guest] no , i do n't think so . [doctor] okay , thank you . well , let's complete his exam and then we'll talk about the next steps . [patient_guest] okay , sounds good . [doctor] can you take a big breath randy . [patient_guest] where's mama ? [doctor] do n't forget to breathe little one . okay . let's try the front too . [patient_guest] yeah , it's okay buddy . [doctor] excellent . he's doing excellent . next let's- let's check out those ears . [patient_guest] okay . [doctor] let's try to make sure you do n't tip all the way over . [patient_guest] dino , you're doing so good . [doctor] all right . ears look okay . we're going to slide you forward so you do n't bump your head when i lay you down . [patient_guest] hey , you're- hey you're okay . you're okay . [doctor] okay , you can go ahead and sit him back up if you like . [patient_guest] all right . thank you . [doctor] all right . so , he's just kind of getting started with this , and i think we're seeing something viral right now . often sinus infections will start out as a virus and then will become bacterial infections if left alone and does n't go away . but , i do n't think he needs any antibiotics , at least not at this point in time . um , keep up with the fluids , rest , and i would watch him very carefully for a barking cough . if he does get a barky cough , then that tends to be a little bit more significant and a little more severe . so , if he develops a barky cough , i want you to give him a half a teaspoon of his sister's medicine . [doctor] you know , i'm almost tempted to give you some of the medicine because they're probably sharing the same virus . [patient_guest] okay . [doctor] actually , i will . i'll go ahead and just give you some as well . [patient_guest] okay . okay . [doctor] but , if he does n't become barky , you do n't have to use it . it only works for the barky cough . [patient_guest] mm-hmm , got it . [doctor] okay . we'll do the same thing with him , as long as nothing gets worse , and we'll see him back in one week . so , it wo n't get rid of a regular cough . he can use zarbee's , but use the dose for kids under a year of age . so , if you wan na get some of that , you can definitely try that for him , it can help out a little bit with the regular cough . [patient_guest] i do have a question . do you or do you not give honey to babies ? [doctor] yes , that's a great question . you do n't give honey to kids under a year , instead , you can give them agave , which is a different type of nectar . um , now you can give honey to his older sister , that is okay , but for him , it would not be very good because his stomach acid's not good enough to break down the botulism spores . so , it'd cause him harm . um , you should look at the package of say , honey nut cheerios . it says right on there to not give it to a baby . [patient_guest] okay . [doctor] now , whether that would really hurt a baby , i am unsure , but it has real honey in it . so , no honey for him , but agave is definitely fine . [patient_guest] okay . so , zarbee's for the stuffy nose . [doctor] yes , zarbee's . [patient_guest] and then you said , uh , which medicine to give him just in case ? [doctor] i'm gon na give him the same medicine as his sister , and just hang onto it , um , just to watch and see . if this was a monday and we had a whole week to watch , i would say to just call us if things got worse , um , but since , um , if it's gon na be the weekend , and things might worsen tonight or tomorrow night , i'd rather you have just what you need on hand . [patient_guest] okay . [doctor] right , does that make sense ? [patient_guest] yeah , yeah . that makes sense . [doctor] okay , great . and that way you do n't have to share , um , with his sister . [patient_guest] right , okay . [doctor] and since he's about half her size , we'll do half the dose , which is a half a teaspoon . [patient_guest] okay . will this information all be in the papers ? [doctor] yes . and so , if he ends up starting the medicine , just give him a half a teaspoon for five days . [patient_guest] okay . [doctor] yeah , that's the only thing it wo n't say is , " as needed , " or anything like that . [patient_guest] mm-hmm , understood , thank you . [doctor] you're welcome . [patient_guest] and the cradle cap ? [doctor] what i would do is use something like either head & shoulder's , or selsun blue , or nizoral ad . now , do n't get the extra strength stuff , just use the regular strength . um , cradle cap , it's just basically a fancy way of saying dandruff . so , those shampoos will help get rid of it . it's not an immediate thing 'cause they , um , they are all dead scales , and you still have to brush them off . so , continue to use the soft brush and some baby oil , or something that will help get the scales out , and those shampoos will actually help to prevent it as well . use it two times per week , not every day , but maybe twice a week . [doctor] so , two days between shampooing , use what you normally use any other time . and then , often , within six weeks or so , you'll notice that the-the cradle cap is just , um , not coming back anymore . but , he has to be careful because it's not ph balanced for eyes . so , just make sure when you're rinsing his hair you avoid his eyes . [patient_guest] okay . okay . [doctor] all right . and , if it keeps getting worse , definitely let us know . [patient_guest] okay . sounds good . [doctor] good . and , since they do n't have covid-19 , you can go right ahead and check out . [patient_guest] okay . and both appointments in the week ? [doctor] correct . we'll see you all then . bye randy , feel better . [patient_guest] all right , great . thank you so much . [doctor] you are welcome , and have a good rest of your day .

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

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

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

[doctor] hi , brian . how are you ? [patient] hi , good to see you . [doctor] it's good to see you too . so , i know the nurse told you a little bit about dax . [patient] mm-hmm . [doctor] i'd like to tell dax about you , okay ? [patient] sure . [doctor] so , brian is a 58 year old male with a past medical history significant for congestive heart failure and hypertension , who presents today for follow-up of his chronic problems . so , brian , it's been a little while i've seen you . [patient] mm-hmm . [doctor] whats , what's going on ? [patient] i , i just feel out of sorts lately . i do n't know if it's the change in the seasons or if we're just doing a lot of projects around the house and , and some , some construction on our own . i'm just feeling out of it . lack of , uh , energy . i'm just so tired and fatigued , and i feel kinda ... i feel lightheaded every once in a while . [doctor] okay . all right . um , how long has that been going on for ? [patient] uh , probably since labor day , so about five weeks or so . [doctor] okay . and , have you noticed any , like , symptoms of weight gain , like , like swollen legs , or , you know , your belly feels bloated and things like that ? [patient] i feel , i feel bloated every once in a while . [doctor] okay . all right . um , and , are you taking your , your medications ? [patient] uh , yes , i am . [doctor] okay . and , how about your diet ? are you watching your diet ? [patient] uh , it's been a little bit of a struggle . we began construction on our kitchen over labor day weekend , and it was ... hard to cook or prepare meals so we ate out a lot, and not always the best food out. it , it , it kind of reeked havoc , uh , so it's been maybe off a little bit . [doctor] okay . all right . and , how about , you know , other symptoms , like , have you had a fever or chills ? [patient] no . [doctor] okay , and any problems breathing ? do you feel short of breath ? [patient] uh , just when i'm doing doing the projects . again , not even lifting anything really heavy , it's just that if i'm ex- exerting any energy , i , i kinda feel it at that point . [doctor] okay . do you have any chest pain ? [patient] slight cramps . that seems to go away after about , maybe about an hour or so after i first feel it . [doctor] okay , and how about a cough ? [patient] a , a slight cough , and again , i'm not sure if it's just the change of seasons and i'm getting a cold . [doctor] mm-hmm . okay . all right . well , you know , for the most part , how , you know , before all of this- [patient] mm-hmm . [doctor] . how were you doing with your heart failure ? i know that we've kinda talked about you being able to watch your healthy food intake and that's been kind of a struggle in the past . [patient] i , i , i've actually been pretty good about that ever since . the , the , the last year , it's been a little chaotic , but i wanted to make sure i stayed on top of that . [doctor] okay . all right . are you excited for halloween ? [patient] uh , ca n't wait . [doctor] okay . [patient] our home renovations should be complete by then [doctor] all right , yeah , right . [patient] yeah . [doctor] and , so , lastly , for your high blood pressure , how are you doing with that ? have , are , did you buy the blood pressure cuff like i asked ? [patient] yeah , i , i did , and we do mon- , i , i monitor it regularly . my wife makes sure i stay on top of that , but it's been pretty good . [doctor] okay . all right . well , i know you did the review of systems sheet when you checked in , and you were endorsing this fatigue- [patient] mm-hmm . [doctor] . and a little dizziness and we just talked a lot about a lot of other symptoms . [patient] mm-hmm . [doctor] any other symptoms i might be missing ? nausea or vomiting , diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . well , i just want to go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey , dragon ? show me the vital signs . so , looking at your vital signs here in the office , everything looks good . you know , your blood pressure and your heart rate and your oxygenation all look really good . [patient] mm-hmm . [doctor] so , i'm gon na just take a listen to a few things and check some things out , and i'll let you know what i find , okay ? [patient] perfect . [doctor] okay . so , on your physical examination , you know , i do appreciate some jugular venous distention to- [patient] mm-hmm . [doctor] to about eight centimeters . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which we've heard in the past . and , on your lung exam , i do appreciate some fine crackles at the bases bilaterally , and your lower extremities have , you know , 1+ pitting edema . so , what does all that mean ? that means i think you're retaining a little bit of fluid . [patient] mm-hmm . [doctor] okay ? i wan na just go ahead and look at some of your results , okay ? [patient] sure . [doctor] hey , dragon ? show me the chest x-ray . so , looking here at the results of your chest x-ray , it does look like you have a little bit of fluid in your lungs there , and that can be just from , um , your heart failure , okay ? hey , dragon ? show me the echocardiogram . so , this is the echocardiogram that we did about four months ago , and this shows that the pumping function of your heart is a little bit reduced at 45 % , and it also shows that leaky valve , the mitral regurgitation that , that you have , okay ? um , so , let me just go over and talk about , a little bit , my assessment and my plan for you . [patient] mm-hmm . [doctor] okay ? so , for your first problem , your congestive heart failure , i think you're retaining fluid , and i wan na go ahead and increase your lasix to 80 mg once a day . [patient] mm-hmm . [doctor] i want you to weigh yourself every day . i want you to call me if you're gaining more weight . [patient] mm-hmm . [doctor] and , i certainly want you to call me if you have any other symptoms of shortness of breath , and i wan na go ahead and order another echocardiogram , okay ? [patient] sure . [doctor] hey , dragon ? order an echocardiogram . lastly , for your high blood pressure , it looks like you're managing it well at this time , okay ? so , i wan na go ahead and continue with the lisinopril 20 mg a day . i want you to continue to record your blood pressures at home , and report them to me in the patient portal if you see they're getting elevated , okay ? [patient] mm-hmm . [doctor] does that sound like a plan ? [patient] that sounds fine . [doctor] okay . um , i'm gon na be in touch with you after we get your test results , and we'll go from there , okay ? [patient] sure . [doctor] all right . hey , dragon , finalize the note .

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

[doctor] hey matthew i see here that you've had some back pain for a while and your pcp sent you over to see me how're you doing today [patient] pretty good i'm feeling pretty good do n't like the weather you know i've been sitting in the waiting area for you know thirty minutes and that definitely makes the symptoms worse [doctor] okay well first of all i i agree with you the weather has kinda been all over the place been hot and been cold and and and now it seems like we've had a week of pretty chilly weather hopefully that changes pretty soon so tell me a little bit about when when your back pain started and and and what happened there [patient] well you wan na hear the long story or kind of the short story because my back has been bothering me for a long time [doctor] so let's do let's do the reader's digestive version [patient] well i ca n't i ca n't really tie my shoes you know standing really makes it bad you know when i go to the mall it really really i do n't know all i i've just been bedridden [doctor] okay and i know it got real bad about a month ago that's what the report here from the pcp said but can you tell me exactly where the pain is in your lower back can you kinda point to where that's at [patient] yeah it's right here and you know like thirty years ago when i fell off the roof it was really really bothersome they they said maybe there was a fracture or something and you know i do n't know i just could n't play football and then i had to you know kinda try to take care of myself but you know it's it's been really bad for about a month [doctor] okay and then do you still have that pain that radiates down your left leg sometimes [patient] yeah of course yeah it goes all the way through here [doctor] okay and then so it looks like you pointed to your lower back area and then pointed down through your hip and down into your to your left leg can you describe that pain for me [patient] it's like a electrical tooth ache and it it it goes down the whole leg [doctor] okay and can you rate that pain for me right now zero being none ten being the worst pain you've ever been in in your life [patient] right now it's less bad i did n't take my medications because i wanted you to see me as as i am but it's six out of ten but when it gets really bad i'd say it's thirteen out of ten [doctor] okay and anything that you do make it feel better you mentioned that you know sometimes sitting or laying down anything there make that better [patient] yeah like i said it the only thing that seems to make it better is laying down [doctor] okay [patient] you know standing walking seems to make it worse coughing sneezing makes it worse and you know i had a friend that saw you and you know you burned some nerves or something like that and so i was just seeing if there was something that you could do to get me out of this pain and hopefully you can do it today [doctor] okay and then any numbness or tingling in in your lower extremities or any weakness there in your legs [patient] you know it it's my back that's weak and my legs are weak both of them you know coughing sneezing seem to make it worse so sorry i'm just trying to be like a typical patient because most patients they do n't answer the darn questions so you you know all this time i still have n't gotten a chief complaint out of them so i love the way that you're trying to redirect and so you know what your doctor said you had back pain and leg pain but for me the most important thing for me to capture is that it's in the hip side of the leg side of the calf goes to the big toe and so i need them to be able to give me a perfect sort of root signature so i can hone in is that four five disk seen on the mri really significant or is it on the opposite side but again i'm sorry i'm purposely trying to be in a difficult patient because some of these patients he asked them fifty different questions they wo n't answer any of them so anyway sorry about well [doctor] that's okay [patient] to explain but this is what i deal with every single day [doctor] absolutely [patient] lot of pain yeah you know what my pain is eight out of ten it goes in the back goes into the hip side of the leg side of the calf goes to the big toe my foot kinda drags when i walk i've been having to use a cane nothing seems to make it better and but very few patients will give you the perfect history and most people will start talking about you know when something happened or go back to thirty years ago and you wan na redirect them to their current symptom but the patients wo n't rarely ever tell you what the chief complaint is you you got ta pull it out of them [doctor] so let's take a a quick look at you here okay let's do a physical exam real quick so your vitals look good which is a good thing now on your back exam i do n't see any bony abnormalities no redness or no and no bruising present now do you have pain when i press here [patient] no it's right here [doctor] okay so positive for pain to palpation at the l4 vertebrae and if you bend forward do you have pain there [patient] it hurts all the time especially sitting in these run office desks [doctor] okay so you are positive for pain with flexion and extension of your back i'm going to go ahead and test the strength of your legs now push out against my hands for me please [patient] okay that's it that's all i got [doctor] alright so four out of five strength in the left and five out of five on the right does look like that reflexes are brisk and motor and sensory is intact in both lower extremities i do wan na review the results of your mri the mri shows a disk herniation at the level of l4 l5 vertebrae and it is associated with some nerve root impingement and what that means is the nerve is being compressed by that herniation so let me tell you a little bit about my assessment and plan okay so for the diagnosis of of acute disk herniation at l4 l5 with that nerve root impingement that's causing that pain down your leg and your lower back pain now i know you've tried nsaids in the past without relief and you've done some pt so what i'm going to do is i'm gon na recommend an epidural steroid injection and we're gon na do that today for you if you agree to it what that means is gon na place some anti-inflammatory medication right at the spot of inflammation and once that's in place i wan na refer you back to pt and we wan na strengthen that area mkay you're young and otherwise healthy i think you'll do well but it can take about two to three weeks for that injection really to take full effect so then i want you to see pt and i want you to see me again in about a month are you okay with that treatment plan [patient] sure sounds good [doctor] alright sounds good i'm gon na have the nurse come in and get you prepped and then we'll get that injection for you

CHIEF COMPLAINT Psoriatic arthritis management. HISTORY OF PRESENT ILLNESS Judy Gomez is a 61-year-old female who presents to the clinic today for ongoing management of psoriatic arthritis. Ms. Gomez is currently taking methotrexate and prednisone 1 mg daily. She believes methotrexate has been relieving her joint pain. The patient reports she has been doing well since her last visit. She has been able to decrease her prednisone dose to 1 mg daily; however, she took 2 mg for a couple of days due to increased pain in her bilateral feet. The patient states when she received her first COVID-19 vaccine she held her methotrexate and felt "horrible" all week until the next Wednesday when she took it. She felt better by the end of the week. She did not hold methotrexate for her second COVID-19 vaccine. PHYSICAL EXAM Musculoskeletal: Full range of motion. Dystrophy of all the nails of the toes. ASSESSMENT • Psoriatic arthritis. • High risk medication use. PLAN Psoriatic arthritis. Stable on methotrexate and prednisone 1 mg daily. The patient will discontinue prednisone and continue methotrexate. INSTRUCTIONS The patient will follow up in 3 months.

[doctor] hi , albert . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , albert is a 62-year-old male , with a past medical history significant for depression , type 2 diabetes , and kidney transplant , who is here today for emergency room follow-up . [patient] mm-hmm . [doctor] so , i got a notification that you were in the emergency room , but , but what were you there for ? [patient] well , i , uh , i was n't really , uh , staying on top of my , uh , blood sugar readings , and i felt kinda woozy over the weekend . and i was little concerned , and my wife wanted to take me in and just have me checked out . [doctor] okay . and , and was it , in fact , high ? [patient] yeah , it was . [doctor] okay . did you ... were you admitted to the hospital ? [patient] uh , no . [doctor] okay . all right . and , uh , are you ... did they see a reason , as to why it was elevated ? [patient] uh , yeah . my mother was actually in the hospital the last week. she had a bit of a fall and had to do a hip replacement. she's feeling better now but we have been just grabbing meals at the cafeteria or picking up fast food on our way home and i just really was n't monitoring what i was eating . [doctor] okay . that's sorry to hear . and are you feeling better now ? [patient] uh , actually , when we got home from the , uh , f- from the visit , i felt a lot better . [doctor] okay . and since then , have you been following your diet pretty closely ? [patient] yes . [doctor] okay . 'cause we do n't wan na end up in the hospitaltoo [patient] no . [doctor] all right . um , okay . and , so , before that happened , how are you doing with your diet ? [patient] uh , during the week , i've been fine , 'cause i've been very busy . on the weekends , doing things . you're seeing people . you're having people over . it's , i- not , not as consistent on the weekend . [doctor] okay . all right . um , is there a way that you think that that can improve ? [patient] uh , s- stop eating . [doctor] okay . all right . well , let's talk about your , your kidney transplant . how are- [patient] mm-hmm . [doctor] . you doing ? you're taking immunotherapy meds ? [patient] yes . [doctor] okay . [patient] yeah . i've , i've been pretty diligent about it , following doctor's orders , so it's been , it's been pretty good so far . [doctor] okay . and , and y- the last time i saw that you saw dr. reyes , was about three weeks ago , and everything seemed to be fine . [patient] that's correct . [doctor] your kidney function is good . [patient] yes . [doctor] okay . all right . and in terms of your depression , how are you , how are you doing ? [patient] and it's been about a , a tough , ugh , year-and-a-half or so , but i've been pretty good with it . i , i have my moments , but i- as long as i find some time to relax , at least in the afternoon , then , then it seems to work out okay . [doctor] okay . so , i know that we've kind of talked about holding off on medical therapy- [patient] mm-hmm . [doctor] . 'cause you're on so many other meds . [patient] mm-hmm . [doctor] um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ? [patient] uh , i think i probably wan na shy away from any therapy . my , my wife got me into meditation recently and , and , uh , i , i find that relaxing . so , i think i'd like to continue that , at least for a couple more months and see how it goes . [doctor] okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you- [patient] mm-hmm . [doctor] . checked in . do you have any symptoms , any chest pain or shortness of breath ? [patient] none whatsoever . [doctor] lightheadedness ? dizziness ? [patient] no . [doctor] no ? okay . um , and i just wan na go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey , dragon . show me the vital signs . [doctor] so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be . [patient] mm-hmm . [doctor] so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ? [patient] sure . [doctor] okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past . [patient] mm-hmm . [doctor] your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ? [patient] mm-hmm . [doctor] um , so , let's go ahead . i wan na look at some of your results . okay ? [patient] sure . [doctor] hey , dragon . show me the glucose . [doctor] so , right now , your blood sugar is about 162 . have you eaten before you came in here ? [patient] i did not . [doctor] okay . all right . um , hey , dragon . show me the diabetes labs . [doctor] okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high . [patient] mm-hmm . [doctor] so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated . [patient] mm-hmm . [doctor] so , we'll talk about , you know , how to go ahead and , and fix that . okay ? [doctor] so , let me talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further . [patient] mm-hmm . [doctor] okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , dragon . order a hemoglobin a1c . [doctor] for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ? [patient] mm-hmm . [doctor] okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications . [patient] okay . [doctor] um , and then , he knows to reach out to me if he needs anything . okay ? [patient] you got it . [doctor] all right . well , the nurse will be in soon to check you out . okay ? [patient] perfect . [doctor] hey , dragon . finalize the note .

CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Elizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension, who presents for her annual exam. It has been a year since I last saw the patient. The patient reports that she is doing well. She has been to multiple events now that she has been able to get vaccinated for COVID-19. She reports that she has been able to see her grandchildren again and attend birthday parties. Regarding her depression, she has been going to therapy once a week for the past year. She reports that she is starting to go in person rather than virtual, which has helped even more. The patient has a good support system at home with her husband and her children live down the street. The patient reports that her blood pressure has been doing well. She has been using the blood pressure cuff once a day and her readings seem normal. She has continued to utilize Lisinopril 20 mg daily, as prescribed. The patient endorses nasal congestion. She denies any other symptoms of chest pain, shortness of breath, abdominal pain, nausea, or vomiting. REVIEW OF SYSTEMS • Ears, Nose, Mouth and Throat: Endorses nasal congestion. • Cardiovascular: Denies chest pain or dyspnea. • Respiratory: Denies shortness of breath. • Psychiatric: Endorses depression. PHYSICAL EXAMINATION • Neck: No carotid bruits appreciable. • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Slight 2/6 systolic ejection murmur, stable. • Musculoskeletal: Trace lower extremity edema bilaterally. RESULTS Electrocardiogram stable in comparison to last year. ASSESSMENT AND PLAN Elizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension. She presents today for her annual exam. Depression. • Medical Reasoning: She is doing well with weekly therapy. She also has a solid support system at home. • Medical Treatment: Continue with therapy and current management strategies. We will defer medication at this time. Hypertension. • Medical Reasoning: This is well controlled based on daily home monitoring. She has been compliant with lisinopril. • Medical Treatment: Continue lisinopril 20 mg daily. • Patient Education and Counseling: I advised her to continue with daily home monitoring of her blood pressures. She will contact me via the patient portal for any elevation in these readings. Healthcare maintenance. • Medical Reasoning: She is due for her annual mammogram. • Additional Testing: We will order a mammogram for her. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[doctor] hey lawrence how're you doing [patient] i'm doing alright aside from this elbow pain [doctor] so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain [patient] so i really during this pandemic i really got into ceramics and doing pottery so i've been doing a lot of pottery and over the past week i then started to develop this elbow pain [doctor] okay and then so tell me a little bit more about that elbow pain where does it hurt exactly [patient] you know it hurts a lot in the inside of my elbow [doctor] okay so the inside of your right elbow okay [patient] yeah [doctor] and then does the pain radiate down your arm or up into your shoulder or anything like that [patient] it does n't go into my shoulder it's it stays mostly at my elbow but it can go down a bit into my forearm [doctor] okay and then do you remember any trauma did you hit your arm or elbow or any on anything [patient] no nothing i i really was trying to think if there is anything else and i ca n't think of anything [doctor] okay and you've never injured that right elbow before [patient] no [doctor] alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life [patient] i would say probably a six [doctor] okay and does that pain keep you up at night [patient] it does [doctor] okay and when you have that kind of pain does it keep you from doing other type of activities [patient] yeah i mean i still try to like work through with using my arm but yeah it's it's it's difficult for me sometimes to lift and do things because of that pain [doctor] okay and then and how long has this pain been going on [patient] about four days now [doctor] alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief [patient] i've tried ibuprofen that helps a little but not much [doctor] okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here [patient] yes i do [doctor] okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that [patient] not really [doctor] okay now turn your wrist in so do you have any pain when you do that [patient] yeah that hurts [doctor] okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist [patient] yes i do [doctor] alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend [doctor] that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay [patient] alrighty [doctor] alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week [patient] alright thank you [doctor] thank you

CHIEF COMPLAINT Psoriatic arthritis management. HISTORY OF PRESENT ILLNESS Judy Gomez is a 61-year-old female who presents to the clinic today for ongoing management of psoriatic arthritis. Ms. Gomez is currently taking methotrexate and prednisone 1 mg daily. She believes methotrexate has been relieving her joint pain. The patient reports she has been doing well since her last visit. She has been able to decrease her prednisone dose to 1 mg daily; however, she took 2 mg for a couple of days due to increased pain in her bilateral feet. The patient states when she received her first COVID-19 vaccine she held her methotrexate and felt "horrible" all week until the next Wednesday when she took it. She felt better by the end of the week. She did not hold methotrexate for her second COVID-19 vaccine. PHYSICAL EXAM Musculoskeletal: Full range of motion. Dystrophy of all the nails of the toes. ASSESSMENT • Psoriatic arthritis. • High risk medication use. PLAN Psoriatic arthritis. Stable on methotrexate and prednisone 1 mg daily. The patient will discontinue prednisone and continue methotrexate. INSTRUCTIONS The patient will follow up in 3 months.

[doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened [patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april and we were at the courts plan and i went up for a shot and he's far more aggressive than with me than he is with you know his peers i guess he could say and so he he found me while i was going for a lap and then when i came down i kind of landed awkwardly and i kind of like rolled and twisted my my ankle so now it's it's hurting a bit like kind of on the outside you can you can even see it's it's bruised up and a bit swollen [doctor] yeah [patient] and yeah i've been having trouble walking and it just does n't feel solid really stable which is a problem i i recently got back into working out and i had been in a really good rhythm going to the gym [doctor] okay [patient] and i do n't want to disrupt that moments on because it took a lot for me to get back to a good place so [doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way [patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys [doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad [patient] yeah yes [doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too [patient] yeah a little bit [doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all [patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid [doctor] sure so it does n't quite feel stable [patient] yeah [doctor] okay okay i gotcha so i know you had an x-ray as you came in today and so i'm just looking at this x-ray here i'll show you on the screen right here i can turn my monitor towards you this is an ap lateral oblique and this is your right ankle so what we're looking at is a displaced lateral malleolus at the weber c level there's no evidence of medial or posterior malleolar fractures but this is a fracture on the lateral side of your ankle now based on the position it's a bit unstable that's why you're feeling some of that that instability when you're walking so for your diagnosis what i'm gon na put down is a lateral malleolar fracture and what i would recommend for that since it is in the location that it is is you're probably unfortunately gon na need surgery we're gon na wan na get that healed what that includes is putting some plate and some screws in and you're gon na be out for a little bit so i know you've been trying to work out and and you wan na get back on the court but but you may have to have to sit out for a little bit we'll get you some crutches [patient] how long it's a little bit because i'm also i i forgot to say i'm also i did volunteer to coach [doctor] great [patient] starting in april so [doctor] alright well [patient] how long [doctor] yeah you you're probably gon na be out for about three months but continue the coaching go ahead and and let's get you back out there we'll get you some crutches and and hopefully you can kinda you know get back on the court start coaching and then within that three months we'll we'll get you back out doing some exercise again [patient] okay [doctor] alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly [patient] yeah i i work from home so that that should n't be a problem it's just everything else i do n't know who is gon na walk my dogs and and do all this stuff that's rest of my family refuses to walk my dog so we'll figure it out [doctor] yeah i i'm a dog walker as well so alright sorry for the bad news but let's get you healed up so that we can get you back out doing everything you need to do [patient] alright thank you doctor [doctor] alright thanks

CC: Left shoulder pain. HPI: Ms. Anderson is a 44-year-old female who presents today for an evaluation of the left shoulder. She states that she was in gymnastics 1 week ago. The pain has been present since that time. She has pain with any type of movement of her left shoulder. She had taken Tylenol for 2 to 3 days with no improvement in her symptoms. She has a surgical history significant for prior left upper extremity surgery. EXAM Examination of the left shoulder shows pain with range of motion. RESULTS X-rays of the left shoulder, 3 views obtained on today's visit show no obvious signs of fracture. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended taking ibuprofen 600 mg three times per day for one week. If the patient does not have relief from the ibuprofen she will take Aleve. The patient may also utilize ice or heat packs. She should rest her left arm and may not lift or carry heavy objects with her left arm. The patient should follow up in three to four weeks if the pain persists. We may repeat the left shoulder x-ray at that time.

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

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

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

CHIEF COMPLAINT Right knee pain. REVIEW OF SYSTEMS Cardiovascular: Denies chest pain. Respiratory: Denies shortness of breath. Gastrointestinal: Denies abdominal pain. Musculoskeletal: Reports right knee pain. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. No wheezes. Cardiovascular - Auscultation of Heart: Grade 2/6 systolic ejection murmur. Some edema and effusion noted around the right knee. Musculoskeletal - Examination: Right knee - Palpation: Pain to palpation of the medial aspect. No pain to palpation of the lateral aspect. - ROM: Pain with flexion and extension. -Some effusion noted around the right knee. RESULTS X-rays of the right knee were taken. These show no fractures or bony abnormalities. ASSESSMENT AND PLAN 1. Right knee MCL strain. - Medical Reasoning: Based on the physical examination findings, the patient has a MCL strain of the right knee. - Medical Treatment: I have prescribed ibuprofen 800 mg twice a day. I will also place him in a knee brace. I advised him to ice the knee for 20 minutes at a time for 3 to 4 times a day. The patient was instructed to elevate his leg as needed and avoid strenuous activities for 2-3 weeks. 2. Hypertension. - Medical Treatment: The patient will continue lisinopril 20 mg daily. I have also provided a referral to see a nutritionist for dietary changes. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

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

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

[doctor] patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable . [doctor] worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . 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 lo- are noted . [doctor] hello , mr . ward . nice to meet you . i'm dr. flores . [patient] hi , doc . nice to meet you . [doctor] i was just reviewing your records from dr. howard and he's referred you because the workup for headaches revealed a mass on your pituitary gland . i did review your mri images and you have a significant mass there . can you tell me about the issues you've been experiencing ? [patient] yeah sure . so i'm really getting fed up with these headaches . i've been trying my best to deal with them but they've been going on for months now and i'm really struggling . [doctor] where are the headaches located and how would you describe that pain ? [patient] located behind my eyes . it's like a dull nagging ache . [doctor] okay . was the onset gradual or sudden ? [patient] well it started about three months ago . and they've been getting worse over time . at first it was like three out of 10 severity , and it just gradually worsened . and now it's about six out of 10 severity . the headaches do tend to be worse in the morning and it feels like a dull ache behind the eyes . they last a few hours at a time , nothing makes them better or worse . [doctor] okay . can you tell me if the pain radiates , or if you have any other symptoms ? specifically feeling sick , fever , rashes , neck stiffness , numbness , weakness , passing out ? [patient] no . i have n't been sick or felt sick . ca n't recall a fever or any kind of rash . no- no neck issues , no numbness , no tingling . and i've never passed out in my life . but , um , for some reason recently i seem to be bumping into door frames . [doctor] okay . have you noticed any change in your vision or with your balance ? [patient] no i do n't think so . my eyes were checked in the fall . [doctor] okay . let's see , do you have any other medical problems that you take medicine for ? [patient] no i do n't have any medical problems and i do n't take any medicines . i tried tylenol a few times for the headaches but it did n't work , so i stopped . [doctor] i see . anyone in your family have any history of diseases ? [patient] i was adopted so i really have no idea . [doctor] okay . um , what kind of work do you do ? and are you married ? [patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house . [doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ? [patient] nope . i do n't do any of those and never have . [doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done . [patient] sounds good , doc . [doctor] all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . visual field testing reveals bitemporal hemianopia . and color vision is normal . [doctor] all right , mr. ward . i'm going to review these pictures from the mri with you . um , now this appears to be a benign pituitary adenoma , but there's no way to be sure without sending the removed adenoma to pathology to make the diagnosis , which we will do . um , here you can see it's a well defined mass . and it's pressing right here on what we call the optic chiasm . and today when i was having you look at my fingers , you could n't see them off to the sides , that's what we call bitemporal hemianopia . and explains why you have been bumping into door frames . [patient] yeah i never noticed that i could n't see out of the side until you did that test , and you closed one eye with both eyes . i really could n't tell . [doctor] no because you're having this vision loss from the mass compressing the optic chiasm , the only option we have is to do surgery . [patient] okay , i understand . do you think i'll regain my vision ? [doctor] well there's no guarantees , but it is a possibility . i'm gon na refer you to the eye doctor for a full exam and they'll do what's called visual field test . this will map our your peripheral vision or side vision prior to surgery . and we can monitor after surgery to see if your vision is improving . [patient] all right . [doctor] and let's discuss the surgery a little more . um , we would do what's called a transsphenoidal approach to do the surgery . this is minimally invasive and we go through the sphenoid sinus . there are some risks i have to inform you of . uh , risk of anesthesia including but not limited to the risk of heart attack , stroke , and death . risk of surgery include infection , need for further surgery , wound issues such as spinal fluid leak or infection , uh , which may require long , prolonged hospitalization or additional procedure . uh , seizure , stroke , permanent numbness , weakness , difficulty speaking , or even death . [patient] well i guess we have to do it regardless . [doctor] okay . so i will have you see our surgery scheduler , deborah , on the way out to get you set up . we will get this scheduled fairly quickly so i do n't want you to be alarmed . um , she'll also get you set up today or tomorrow to have the visual field test and you may not be able to see the eye doctor until after surgery . but we have the pre-surgery visual field test for comparison after surgery . [patient] okay . i look forward to these headaches going away . i never thought it could be something like this going on . [doctor] yeah . come this way , we'll get your things lined up . please call if you think of any questions . [patient] thanks , doctor . [doctor] diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note .

CHIEF COMPLAINT Status post mitral valve repair. HISTORY OF PRESENT ILLNESS Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020. On 09/17/20 we saw Mrs. Sanchez in office, and she was doing well and thus we recommended maintaining her current medications, she is using a reminder app to stay compliant with medications. The patient reports feeling better and overall, pretty good. She denies experiencing new symptoms. She is still having chest pain intermittently, and her breathing “gets shallow” which results in her “slowing down” and decreasing her exertion. An episode of shortness of breath and chest pains may last a few minutes and will not recur for a few weeks. PAST HISTORY Medical Mitral regurgitation. Atrial fibrillation. Diabetes Type II. Asthma. Surgical Mitral valve repair 08/03/2020. CURRENT MEDICATIONS Coumadin 4 mg daily. Lasix 40 mg daily. Atenolol 50 mg daily. PHYSICAL EXAM Head and Neck No JVD detected. Respiratory Lungs have reduced breath, but auscultation and percussion are clear. Cardiovascular Rhythm is irregularly irregular, S1 slightly accentuated, no S3. Musculoskeletal Trace peripheral edema on extremities. RESULTS ECG, 12/26/2020. Impression: Atrial fibrillation with a controlled ventricular response, t-wave inversion anteriorly. Compared to the previous study, there are no significant changes. I also recommended that the patient continues to be active within her limits. ASSESSMENT • Status post mitral valve repair Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020. PLAN Continue with current medications. Coumadin 4 mg daily, Lasix 40 mg daily, and Atenolol 50 mg daily. INSTRUCTIONS Return to clinic in 6-9 months.

[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 Asthma. MEDICAL HISTORY Patient reports history of asthma. SOCIAL HISTORY The patient denies the use of any type of cigarette or tobacco product, as well as marijuana. Occasionally, she will be at a bar that allows smoking inside, which does bother the patient. She enjoys being outside and hiking. ALLERGIES Denies seasonal allergies. MEDICATIONS Patient reports using an albuterol inhaler, 2 puffs. REVIEW OF SYSTEMS Respiratory: Reports coughing and wheezing. VITALS Blood pressure: 128/82 mm Hg. Respiratory rate: 16 O2 saturation: 99% on room air. PHYSICAL EXAM Neck - General Examination: Neck is supple without lymphadenopathy. Trachea is midline. No carotid bruit. Respiratory - Auscultation of Lungs: Diminished lung sounds throughout with the occasional slight expiratory wheeze, bilaterally. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No ectopic beats. No rubs, murmurs, or gallops. Musculoskeletal - Examination: Strong bilateral radial pulses. No clubbing. Brisk capillary refill. Hematology/Lymphatic/Immunology - Palpation: No enlarged lymph nodes. RESULTS Pulmonary function test obtained today is reviewed and findings are consistent with asthma. ASSESSMENT AND PLAN 1. Moderate intermittent asthma. - Medical Reasoning: The patient's symptoms and results of her PFT are consistent with moderate intermittent asthma. - Patient Education and Counseling: I explained the importance of consistency with her daily inhaler as this will help prevent daily symptoms and the need to use the albuterol inhaler as frequently. My hope is that she has less acute exacerbations as she continues to use her inhaled steroid. - Medical Treatment: Prescribed provided for Flovent 110 mcg 1 puff twice per day. She can continue using her Ventolin inhaler 2 puffs every 4 to 6 hours as needed. I have recommended using her albuterol inhaler 1 to 2 puffs and then monitor her breathing prior to taking an additional 1 to 2 puffs. I am also going to put together an asthma action plan for her so we know what to do based on her symptoms. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 1 month for reevaluation or sooner for worsening symptoms.

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

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

CHIEF COMPLAINT Left shoulder and elbow pain. HISTORY OF PRESENT ILLNESS Mr. Jose James is a 64-year-old male who presents for left shoulder and elbow pain. The patient reports falling on his hand while going up stairs 5 months ago and has been experiencing constant pain since. He admits he was continuing to complete strength training exercises at least 2 times per week, however, he was unable to lift more than 15-20 pounds due to the pain. During the past 1-2 weeks, Mr. James has discontinued strength training activities. Additionally, he has iced the inflicted areas, denies taking any pain medications, and reports his pain has slightly improved but it is still rather constant. He denies tingling and numbness. The patient walks 30-minutes most days of the week. SOCIAL HISTORY Retired last year, was an office worker. PHYSICAL EXAM Musculoskeletal Left shoulder and elbow, tender subacromial space. No warmth, erythema, or deformity. Positive Hawkins-Kennedy and Neer’s test. Normal proximal and distal upper extremity strength. Intact median, radial, ulnar sensation. Abduction to 90 degrees. Normal empty can test. ASSESSMENT • Impingement syndrome of left shoulder Jose is a 64-year-old male who was seen today for impingement syndrome of his left shoulder, likely related to a fall he incurred 5 months ago. PLAN Today I discussed conservative options for left shoulder impingement with the patient, who opted to try physical therapy 2 session per week. Cortisone injection was discussed as an option if the physical therapy does not successfully reduce his pain. Additionally, I recommended continued ice and rest. INSTRUCTIONS email, or call if symptoms worsen or do not resolve.

[doctor] judy gomez , mrn 869723 . date of birth , 5 , 7 , 1961 . she's in office today for ongoing management of psoriatic arthritis . hello , judy , how are you doing today ? [patient] i'm doing good , thank you . how are you ? [doctor] i'm great , thanks . so how have you been since the last time ? i know the last time we were talking about decreasing your prednisone dose , correct ? [patient] yes . i'm just on one now and that seems to be enough . [doctor] aw , that's great to hear . [patient] yeah , there were a couple days there i took an extra one , just because there was a little extra pain in my feet . and i do have a desk job , so when i have a day off where i'm moving around a lot they do tend to hurt a bit more . [doctor] okay . how many times did you do that ? [patient] um , it was n't often , maybe once a week . [doctor] okay . so it sounds like we're still on track for discontinuing the prednisone . we'll do that today and you can let me know how it goes on your next visit . and how about the methotrexate , do you think that helped with your joint pain ? [patient] yeah , definitely . because i went to get my covid shots , um , but from the letter i got about it , it said that it could interfere with the vaccine , you know , reduce the efficacy . so i did n't take it on the week that i got the first shot . [doctor] okay . and what happened ? [patient] i felt absolutely horrible until i took it again a week later . [doctor] i'm sorry to hear that . and- and what did you do about the second dose ? [patient] well , i called into the hotline because i was in so much pain with the first one . and they said , " no , just go ahead and take it , " so i did . [doctor] okay . that's good then . we do have to keep an eye out on it since it's a high-risk medication . do you have an appointment to get your blood drawn for the next time ? [patient] no , they did n't give me one . [doctor] okay . so we can do that for you too . uhm , so what questions do you have for me , judy ? [patient] well , i just wanted to know why i was getting all these bruises here , so like when i bump myself . i do n't know where they're coming from . [doctor] okay . that's probably from the prednisone , it can increase bruising . [patient] okay . i did n't know that . um , i do n't even feel it when it happens , they just show up . [doctor] yeah . unfortunately that can happen , but we're working on discontinuing that so let's see if the bruises do go away . [patient] okay . that sounds good , thanks . [doctor] okay , judy , please , um , sit up here and i'll take a look . shoes and socks off please . [patient] all right . [doctor] all right . let me see here . okay . so where is it hurting ? in your joints right here ? [patient] yeah , a little . also in my feet joints as well . [doctor] okay . and how about when you bend the knee like this ? [patient] well , it hurt before we increased the methotrexate , but it's doing pretty good now . [doctor] okay , good . can you flex your toes please ? good range of motion . also ridges in nails , that's from the psoriasis . [patient] yeah . they've been like that for a long time now . [doctor] okay . all right , uhm , ms gomez , it looks like we're moving along with your treatment nicely . we'll stop your prednisone and continue with the methotrexate . make sure to stop by the front desk and make an appointment for the blood work , and i'll see you in three months . [patient] all right . it sounds good . thank you so much , it was great to see you . [doctor] it was great seeing you too . thank you .

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

[doctor] hello . [patient_guest] hi . [doctor] i'm dr. evelyn , one of the kidney doctors . it's good to meet you guys . [patient_guest] it's nice to meet you also . [doctor] yeah . so i was reading about this syndrome that i actually have never heard of . [patient_guest] yeah , me too . [doctor] i do n't think it's very common . [patient_guest] definitely not . it's c- pretty rare . [doctor] so- [doctor] can you start at the beginning ? i know she's a twin , so are these your first two babies ? [patient_guest] no , i have a son also who is nine . he also has autism . [doctor] okay . [patient_guest] and when the twins were born , katherine , she was about 4 pounds , 8 ounces . and her twin was a bit smaller , at 3 pounds , 13 ounces . [patient_guest] katherine , she was doing fine . she just had problems with eating , where she would stop breathing when she was eating . [doctor] like preemie type stuff ? [patient_guest] uh- . yeah . she just had a hard time regulating her temperature , but she did fine . she does have a gi doctor , because she has reflex really bad . she also had a dietician , who told us to take her off cow's milk . which we did . and then she has seen an allergist , and also a neurologist ... who diagnosed her with this syndrome , because she still does n't walk and she was n't sitting by herself a year old . [doctor] yeah . [patient_guest] but so now she is crawling and she is trying to take steps , so think she's doing pretty good . [doctor] good . is she in therapy ? [patient_guest] she is in therapy . she's in feeding therapy , occupational therapy , and also physical therapy . [doctor] awesome . okay . [patient_guest] and we also have speech therapy , who is going to be starting within the next couple of weeks . [doctor] that's great . [patient_guest] so , she has a lot of therapies . we have also seen an orthopedic and an ophthalmologist . i can never say that . we have seen everything , really . [doctor] and audiology too , right ? [patient_guest] yes . [doctor] yeah , wow. . [patient_guest] yeah , it has definitely been a whirlwind of stuff . when we saw the geneticist , she told us that sometimes people with this syndrome , they have trouble with their kidneys . that they might actually fuse into one . she also said sometimes they have problems with their legs , so that was why we saw ortho . [doctor] okay . okay . [patient_guest] so we have seen everybody , really . we are just here to make sure that her kidneys are looking good right now . [doctor] yeah , okay . so , um , tell me about how many wet diapers she has in a 24 hour period ? [patient_guest] she has a lot . [doctor] so like normal 8 to 10 , or like 20 ? [patient_guest] yeah , it's around 8 to 10 . [doctor] okay . great . [patient_guest] yeah , she seems to pee a lot , and it feels like she drinks a lot too . [doctor] that's perfect . [patient_guest] and she used to only drink milk , and then i took her off dairy milk . so when i say milk , i actually mean , you know , ripple pea protein milk . [doctor] sure , yeah . [patient_guest] so i give her that milk , water now that she's used to it , and sometimes water with just a little bit of juice . so i do feel like she's drinking a lot better now . [doctor] that's great . and she's how old now ? [patient_guest] she'll be two mo- two next month . [doctor] okay . is her twin a boy or a girl ? [patient_guest] she's a girl . [doctor] okay , and how's she doing ? [patient_guest] she's doing really good . she's running around , and she does n't have any problems . [doctor] all right . is she bigger than her or the same size ? [patient_guest] they're about the same size . they're able to wear the same clothes , so ... [doctor] okay . [patient_guest] i do n't even think she's a pound hav- heavier , actually . [doctor] yeah . yeah . [patient_guest] but she is a little bit taller than her ... um , katherine . she's just sh- a little shorter and chunkier , but i think that's a part of her syndrome . [doctor] yeah . yeah , i was reading all the things associated with the syndrome . it sounds like we're looking for continual- congenital anomalies wi- of the kidney and urinary tract . which is basically something is wrong with the plumbing . [patient_guest] okay . [doctor] so the only way to know that , is to do a kidney ultrasound . [patient_guest] okay , that sounds okay . [doctor] okay . let me put that into the system , and then downstairs they can do the ultrasound . [patient_guest] all right , thank you . [doctor] okay , yeah . where do you all live ? [patient_guest] uh , we live in dallas . [doctor] okay . anybody in the family with kidney failure , dialysis or transplant ? [patient_guest] no . [doctor] okay . so let's get your ultrasound done , and we'll see how it goes . [patient_guest] all right , that sounds good . [doctor] all right . let me take a quick look at her . [patient_guest] sure . [doctor] all right . please use my physical exam template . um , i wan na take a quick listen to her heart and lungs . i'll look in her ears too . and she can sit , she can just sit on your lap . [patient_guest] okay . [doctor] all right . that's it . [patient_guest] all right , that was n't too bad . [doctor] hmm . so , let's complete the ultrasound today . i'll call you with the results . if it's normal , you wo n't need to see me again , but if it's abnormal , you can see me in kennesaw . [patient_guest] okay , that sounds good . [doctor] okay . we'll determine what the next steps are if there are any , after we see her results . [patient_guest] all right , sounds good . thank you . [doctor] you're welcome . the nurse will be in to have you complete some paperwork , and give you instructions for the ultrasound . we'll talk soon . [patient_guest] all right . thank you , and have a good day . [doctor] you too . [doctor] all right . physical exams show the well-nourished female , who is slightly fussy when examined . eyes are small appearing . she has mild hypotonia of the lower extremities in her arms . normal external female genitalia . [doctor] assessment and plan . katherine is a 22-month-old former 34 and 3-week-old , twin with smith magenis syndrome . several organ systems can be affected by this chromosomal deletion syndrome . congenital anomalies of the kidney and urinary tract have been reported in the literature . [doctor] we will obtain the screening of the kidneys by ultrasound today . if there are abnormalities on the kidney ultrasound , we will determine next steps and future follow-up . the family lives in dallas , georgia , so her follow-up should be at the town center location . [doctor] end of recording .

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

[doctor] hello larry how are you doing today [patient] i've been better my primary care doctor wanted me to see you for this back pain that i've been having for a couple of years now [doctor] okay [patient] and i have tried so many things and just nothing seems to work [doctor] i'm sorry to hear that now do you remember what caused the pain initially [patient] you know i never fell or was in an accident but i do remember it all happened like i started having back pain after i was moving furniture one weekend [doctor] okay and now can you describe the pain for me [patient] yeah it feels like a sharp stabbing pain in my back and it does go down even down to my right leg sometimes all the way down to my toe it feels like my big toe [doctor] okay [patient] and i also feel like i just ca n't get comfortable which is worse when i sit down okay yeah [doctor] okay now with that do you have any numbness or tingling associated with your back pain [patient] yeah i do get some numbness and tingling especially to my right leg that goes down to my foot [doctor] okay [patient] let me separate these [doctor] and how about a loss of sensation in the genital or the rectal area [patient] no nothing like that [doctor] okay now do you have any weakness [patient] i would n't say i have any weakness no [doctor] okay do you experience like any loss of control of your bladder or your bowels [patient] no [doctor] okay now you mentioned earlier that you you have some tried tried some things in the past so tell me what were they [patient] so i've tried some physical therapy before and so when it gets really bad they've even had to prescribe some strong pain medications for me but that was only temporary and they even mentioned surgery to me in the past but i really would like to avoid surgery [doctor] okay sure so tell me what is your day like [patient] my day so i try to be as active as i can but of course it's been difficult with my back pain and so because of that i have gained some weight over the past years [doctor] okay alright well i'm sorry to hear that i know that you used to like playing golf [patient] yeah i and you know golf is relatively new for me i've been trying to get into it but this has definitely set me back [doctor] yeah i'm sorry yep probably now at the peak of you know just learning it and being able to do more with it this comes and this happens right [patient] exactly [doctor] well let's see what we can do for you here so you can go out into the you know the golf course again now do you tell me do you have any family members with spine conditions [patient] no i ca n't recall any family members [doctor] okay alright and do you smoke [patient] not now i i quit about twenty years ago [doctor] okay alright well alright well i like to do a quick physical exam on you here [patient] okay [doctor] i'm gon na go ahead here i reviewed your vitals and they overall look pretty good so that's a good sign now on your musculoskeletal back exam there is no overlying erythema and that just means redness or ecchymosis and that just means bruising of the skin now there is midline tenderness at l4 l5 disk space with right-sided lumbar paravertebral tenderness so do me a favor and i'm gon na just have you you know bend forward and straighten up a bit [patient] okay that's painful [doctor] sorry so definitely some pain with lumbar flexion and supine straight leg test is positive so on your neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome okay and i'm just gon na take a look at your knees here real quick and then your your ankles so patellar and achilles reflexes are symmetrical so good now i reviewed the results of your mri and it shows disk herniation with nerve impingement so let me tell you about my assessment and plan here larry so for your problem of chronic lumbar back pain so based on your symptoms your exam and reviewing your mri results your symptoms are consistent with an l4 l5 herniated disk with radicul radiculopathy so this means that one of your disks that sits between your spinal vertebrae is bulging out and this bulge is pinching on some nerves and that's why you feel that tingling in your leg so yeah yeah so i am recommending a spinal injection with a strong inflammatory medication called a corticosteroid and what i do is i will inject the corticosteroid into that lumbar spine under fluoroscopy which you can think of you know an x-ray to help localize to the exact area of your pain now this should this should help the inflammation that is causing the pain so what do you think about that [patient] is there something i'm gon na have to do all the time [doctor] well you know patients are different so what we do is we will monitor you and we see how you respond to the injection and the patient's intervals can be different as well but we usually do not do more than four times a year [patient] okay okay [doctor] alright and it's not a long procedure it's it's relatively quick and common and you should be out of the office within an hour [patient] okay [doctor] okay [patient] alright sounds good [doctor] alright well let's go ahead and get you started on the first one today if that works for you if not we'll get you scheduled to start your first injection [patient] alright thank you [doctor] alright thank you [patient] bye

CHIEF COMPLAINT Hepatitis C. SOCIAL HISTORY Patient reports personal history of intravenous drug use over 15 years ago. She is currently smoking 1-2 cigarettes per day, previously 1 to 1.5 packs per day. She also has a history of heavy alcohol use, but now drinks approximately 1 beer per day, more on the weekends. FAMILY HISTORY Patient reports family history significant for hypertension, diabetes, and depression. REVIEW OF SYSTEMS Constitutional: Reports fatigue. All other systems were reviewed and are negative. VITALS Vitals look good today. PHYSICAL EXAM Constitutional - General Appearance: in no apparent distress. Respiratory - Auscultation of Lungs: No wheezes, rales, or rhonchi. Cardiovascular - Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur, unchanged. Gastrointestinal - Examination of Abdomen: No masses or tenderness. No hepatosplenomegaly. - Auscultation: Bowel sounds normal. Musculoskeletal - Examination: No edema. Integumentary - Examination: No signs of jaundice. RESULTS HCV antibody: Positive AST: 39 ALT: Within normal limits Albumin: Within normal limits Bilirubin, total: Within normal limits ASSESSMENT AND PLAN 1. Hepatitis C. - Medical Reasoning: Her recent blood work revealed a positive HCV antibody. She does have a history of intravenous drug use, but she has not used drugs in over 15 years. - Patient Education and Counseling: We discussed the nature of hepatitis C in detail. I advised the patient to have her spouse and children tested for hepatitis C as well. - Medical Treatment: I'm going to order additional labs including a hepatitis C RNA and HCV genotype to confirm the diagnosis, as well as a Fibroscan to assess the severity of the condition. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 3 weeks.

[doctor] hi jacqueline how are you doing today [patient] i'm doing okay i'm just really anxious about my recent blood work that my pcp did and said that i have hepatitis c i'm just really surprised because i've been feeling fine [doctor] okay so were you ever told in the past that you have hepatitis c [patient] no never [doctor] okay and do do you have any history like iv drug use known that you know or do you have any known to have any like hepatitis c positive partners [patient] i mean like years ago i used to party a lot and even use iv drugs but i've been clean for over fifteen years now [doctor] okay well very good you know congratulations on that that's that's a great great achievement so tell me though how about alcohol use [patient] i used to drink a lot a lot more alcohol now i probably would say i drink about a beer a day [doctor] okay [patient] and maybe slightly more on the weekends but nothing like how i used to [doctor] okay alright how about smoking have you ever smoked [patient] i do smoke i'm down to one to two cigarettes a day it's just really been tough to just get rid of those two but i've cut down a lot i used to i was up to one point or a pack and a half a day [doctor] wow okay alright so yeah you you definitely have decreased that so that's again good for you on that one so hopefully you keep you keep that up [patient] thing [doctor] so tell me do you have any other medication conditions [patient] do i do i no otherwise i'm i'm feel pretty good i had my physical there was nothing else the the only thing i was telling my pcp is i do feel like tend to be really tired at the end of the day after working but otherwise i've been good [doctor] okay and and has work been not hard lately you've been busy it sounds like [patient] i know i have been busy but not really much more than usual [doctor] okay [patient] so that's why i was kind of marking because i mean i used to you know be able and be fine but i just lately have been feeling like i'm getting enough sleep but i still get very tired at the end of the day [doctor] okay alright well i hope you're not working too much and then you'll able to at least find some time with the family [patient] yeah i'm i yeah i tend to be a workaholic but yes i i am working on that [doctor] okay well i hope kids are doing okay [patient] they are thank you [doctor] okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or [patient] yeah all of all of the above [doctor] okay [patient] hypertension diabetes and also depression [doctor] okay and depression okay alright well let's go ahead and do a quick physical exam on you here i reviewed your vitals and everything there looks good so that's good and now on general appearance you appear in no distress and no jaundice on skin exam let me go ahead and listen to your heart here great on your heart exam you have a nice regular rate and rhythm with a two out of six six systolic murmur appreciate appreciated that's that has n't changed from last year so we will just continue to monitor that monitor that as well okay [patient] okay [doctor] alright now let me listen to your lungs here very good so your your lungs are clear with no wheezes rales or rhonchi and let me go ahead and listen to your abdomen great your bowel sounds are present your abdomen is soft with no hepatospleno splenomegaly ca n't talk to appreciated so let me now check your musculoskeletal exam here great i i did n't see any gait disturbance and no edema so that's great so jacqueline i did review the results of your recent blood blood work and your hcv antibody test was positive and your liver panel that was done showing an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so what that all means and let me go ahead and tell you about my assessment and plan here for your first problem of hepatitis c your initial labs are consistent with hepatitis c so based on the the once i just discussed with you there now hepatitis c is a viral infection that affects the liver so you most likely may have had it for years now so the next step that i would like to do is to confirm the diagnosis with some additional blood work that includes checking the hep c rna and also the hcv genotype okay now i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and i'm gon na do this by ordering a special ultrasound and with this information i'm gon na be able to know how to proceed as far as treatment [patient] okay [doctor] alright now i know that was a lot of information do you have any questions for me [patient] yeah so should i be worried about my wife and my kids should they be tested as well [doctor] yes so we can start with the same screening that you have had for you for all of them first okay [patient] okay alright so i'll make sure i'll have them set up an appointment with our our family doctor [doctor] okay great so if you do n't have any other questions i'm gon na have the nurse check you out and get all that scheduled and i'm gon na see you in about three weeks [patient] alright perfect [doctor] alright [patient] thank you [doctor] take care jacqueline [patient] okay bye [doctor] bye

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

[patient] hi kenneth how are you the medical assistant told me that you had some knee pain yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since [doctor] okay so that was about five days ago then [patient] yeah yeah that was last weekend [doctor] last weekend okay now which knee is it [patient] it's my right knee [doctor] your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened [patient] no it just felt like something stretched and then it swelled up some afterwards [doctor] okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance [patient] i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore [doctor] yeah okay and have you ever injured this knee before [patient] no that was the first time [doctor] that was the first time okay where do you have a boat what lake do you have it on lake [patient] lake martin [doctor] okay nice and so you're a frequent water skier [patient] yeah i try to go every weekend when we can [doctor] that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day [patient] no i'm not a baseball fan but i love spring and chicken time of year launds of outdoor activities nice nice i'm i'm not really a baseball fan either but my husband makes me watch the the meds all the time and they lose all the time so he is always upset so so anyway [doctor] yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked [patient] i'm taking it everyday and i check my blood pressure at home and it's been about one twenty five over eighty most of the days [doctor] nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing [patient] not that i know of it's been a good medicine for me and i do n't have any trouble with it [doctor] okay great alright and since you had this knee pain any numbing or tingling in your foot at all [patient] no just the swelling and the pain [doctor] okay and what have you taken for the pain [patient] i i took some aleve twice a day some over the counter aleve twice a day [doctor] okay and [patient] putting a cold pack on it [doctor] okay and has that helped at all [patient] yeah that's helped a fair amount it's still pretty sore though [doctor] okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here [patient] i had my tonsils out [doctor] okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a really good job managing your blood pressure your blood pressure is up is about one twenty over seventy seven today here in the office and that's with you probably in a little bit of pain so that's good and on your neck exam i do n't appreciate any lymphadenopathy on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are clear to auscultation bilaterally on your musculoskeletal exam on your right knee i do appreciate some ecchymosis some edema there is an effusion present does it hurt when i press [patient] yeah that's sore [doctor] okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt [patient] yeah do n't do that anymore [doctor] alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you essentially i agree with you you had quite quite an injury to your knee and you do have a little bit of fluid in your knee there and just some inflammation which i think we need to talk about okay so i wan na go ahead and just talk a little bit about you know my assessment and my plan for you so for your first problem of your right knee pain i do believe you have what we call a a medial collateral ligament strain you know i wan na go ahead and just order an x-ray of your right knee just to make sure that we're not missing any broken bones which i do n't think we are but what's good about this particular injury is that people typically heal quite well from this and they typically do n't need surgery we can just go ahead and refer you to physical therapy to to strengthen those muscles around your knee so that you do n't have another injury and i wan na go ahead and just prescribe meloxicam fifteen milligrams once a day and that will help take down the swelling and help with some of the pain and you only have to take it once a day and it wo n't really cause any upset stomach or anything like that do you have any questions about that [patient] yeah if i start that medicine today am i going to be able to ski tomorrow because we got a a big weekend plan [doctor] i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we have the results of the x-ray and that type of thing okay for your second problem of your hypertension i wan na just go ahead and continue on lisinopril twenty milligrams a day i wan na just go ahead and order an a lipid panel just to make sure everything is okay from that standpoint and then i'm just looking through your health record and it looks like you're due for a tetanus shot so we'll go ahead and just give you a a tetanus shot for a from a health maintenance perspective any other questions [patient] i think so sounds like a good plan to me [doctor] okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye [patient] thank you

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

CHIEF COMPLAINT Kidney stone. MEDICAL HISTORY Patient reports history of hypertension, diabetes, and kidney stones. MEDICATIONS Patient reports taking Norvasc 2.5 mg and metformin 500 mg. REVIEW OF SYSTEMS Constitutional: Reports insomnia. Cardiovascular: Denies chest pain. Gastrointestinal: Denies abdominal pain. Genitourinary: Denies hematuria. VITALS Blood pressure: 150/90 mm Hg PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi. Cardiovascular - Auscultation of Heart: Grade 2/6 systolic ejection murmur, unchanged. Gastrointestinal - Examination of Abdomen: No masses or tenderness. No tenderness of the CVA. RESULTS A1c: 6.7 ASSESSMENT AND PLAN 1. Kidney stones. - Medical Reasoning: Patient recently experience an episode of kidney stones which is her 7th or 8th episode. Based on the patient's symptoms and exam today, I think she has likely passed her kidney stones. - Patient Education and Counseling: I advised the patient that we will obtain further testing, however, based on her recurrent episodes a referral to urology is necessary. - Medical Treatment: Urine culture and urinalysis were ordered. She will be referred to Dr. Harris in urology. 2. Hypertension. - Medical Reasoning: Patient is currently stable and doing well on Norvasc 2.5 mg. - Medical Treatment: Continue Norvasc 2.5 mg. Referral to nutrition provided. 3. Diabetes. - Medical Reasoning: Patient is currently stable and compliant with her metformin. - Patient Education and Counseling: She was advised to start checking her blood sugar prior to every meal. - Medical Treatment: Continue metformin 500 mg daily. Start daily blood sugar monitoring before each meal. 4. Insomnia. - Medical Reasoning: The patient has a history of insomnia. - Patient Education and Counseling: We discussed proper sleep hygiene. - Medical Treatment: I have recommended she take 10 mg of melatonin as needed. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS Patient will return for follow-up in 3 months.

[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 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.

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

CHIEF COMPLAINT 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.

[patient] hi kenneth how are you the medical assistant told me that you had some knee pain yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since [doctor] okay so that was about five days ago then [patient] yeah yeah that was last weekend [doctor] last weekend okay now which knee is it [patient] it's my right knee [doctor] your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened [patient] no it just felt like something stretched and then it swelled up some afterwards [doctor] okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance [patient] i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore [doctor] yeah okay and have you ever injured this knee before [patient] no that was the first time [doctor] that was the first time okay where do you have a boat what lake do you have it on lake [patient] lake martin [doctor] okay nice and so you're a frequent water skier [patient] yeah i try to go every weekend when we can [doctor] that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day [patient] no i'm not a baseball fan but i love spring and chicken time of year launds of outdoor activities nice nice i'm i'm not really a baseball fan either but my husband makes me watch the the meds all the time and they lose all the time so he is always upset so so anyway [doctor] yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked [patient] i'm taking it everyday and i check my blood pressure at home and it's been about one twenty five over eighty most of the days [doctor] nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing [patient] not that i know of it's been a good medicine for me and i do n't have any trouble with it [doctor] okay great alright and since you had this knee pain any numbing or tingling in your foot at all [patient] no just the swelling and the pain [doctor] okay and what have you taken for the pain [patient] i i took some aleve twice a day some over the counter aleve twice a day [doctor] okay and [patient] putting a cold pack on it [doctor] okay and has that helped at all [patient] yeah that's helped a fair amount it's still pretty sore though [doctor] okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here [patient] i had my tonsils out [doctor] okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a really good job managing your blood pressure your blood pressure is up is about one twenty over seventy seven today here in the office and that's with you probably in a little bit of pain so that's good and on your neck exam i do n't appreciate any lymphadenopathy on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are clear to auscultation bilaterally on your musculoskeletal exam on your right knee i do appreciate some ecchymosis some edema there is an effusion present does it hurt when i press [patient] yeah that's sore [doctor] okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt [patient] yeah do n't do that anymore [doctor] alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you essentially i agree with you you had quite quite an injury to your knee and you do have a little bit of fluid in your knee there and just some inflammation which i think we need to talk about okay so i wan na go ahead and just talk a little bit about you know my assessment and my plan for you so for your first problem of your right knee pain i do believe you have what we call a a medial collateral ligament strain you know i wan na go ahead and just order an x-ray of your right knee just to make sure that we're not missing any broken bones which i do n't think we are but what's good about this particular injury is that people typically heal quite well from this and they typically do n't need surgery we can just go ahead and refer you to physical therapy to to strengthen those muscles around your knee so that you do n't have another injury and i wan na go ahead and just prescribe meloxicam fifteen milligrams once a day and that will help take down the swelling and help with some of the pain and you only have to take it once a day and it wo n't really cause any upset stomach or anything like that do you have any questions about that [patient] yeah if i start that medicine today am i going to be able to ski tomorrow because we got a a big weekend plan [doctor] i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we have the results of the x-ray and that type of thing okay for your second problem of your hypertension i wan na just go ahead and continue on lisinopril twenty milligrams a day i wan na just go ahead and order an a lipid panel just to make sure everything is okay from that standpoint and then i'm just looking through your health record and it looks like you're due for a tetanus shot so we'll go ahead and just give you a a tetanus shot for a from a health maintenance perspective any other questions [patient] i think so sounds like a good plan to me [doctor] okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye [patient] thank you

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

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

CHIEF COMPLAINT 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.

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

CHIEF COMPLAINT Non-healing ulcer on his right foot. HISTORY OF PRESENT ILLNESS Nicholas Gutierrez is a pleasant 45-year-old male who presents to the clinic today for the evaluation of a non-healing ulcer on his right foot. The patient was referred from his primary care physician. The onset of his pain began 6 weeks ago, after wearing a pair of shoes that were too tight. Today, he describes a burning, stinging, and throbbing sensation. The patient reports a blister on the pad of the plantar aspect of his foot around his heel. He explains that he has been ambulating on the anterior aspect of his foot. He explains that the top part of the skin of the blister detached, which revealed a thick, soft, mushy skin associated with unpleasant smell and yellow drainage. The patient called his primary care physician, who referred him to our office. He was prescribed a 10-day course of antibiotics approximately 6 days ago. He experienced chills and a fever of 99.7 degrees Fahrenheit. The patient denies any nausea or vomiting. He states that when he started the antibiotics, his foot began to feel pretty good. However, he has now noticed that his foot has turned black around the outside of the wound, and he is experiencing cramping in his calf muscle as well. He also reports a burning red streak that was coming up the front part of his ankle along the inside portion of his calf muscle. While palpating his calf, he has noted stiffness in the muscle that is now up to the patella. The patient reports that he has been coughing a lot over the last 2 days. He has experienced shortness of breath with ambulation around the house. He reports that he purchases new diabetic shoes yearly and changes the inserts every 3 to 4 months. The patient is diabetic and has diabetic neuropathy. He explains that his blood sugar has been trending in the 300 to 400's over the last 2 weeks. At one point, he had a blood sugar spike to either 500 or 600. He states that his last hemoglobin A1c was 6.7, which has been his average for approximately 2 years. The patient checks his blood sugar 2 to 3 times per day and rarely has a blood sugar that goes over 200. He explains that he used to be on an insulin pump and had an A1c that at one point was 13. He states that he worked with an endocrinologist to get it down to where it is now. MEDICAL HISTORY The patient reports a history of diabetic neuropathy. SOCIAL HISTORY The patient enjoys hiking. REVIEW OF SYSTEMS Constitutional: Reports subjective fever and chills Respiratory: Reports cough and shortness of breath with ambulation. Gastrointestinal: Denies nausea and vomiting. Musculoskeletal: Reports right foot pain and right calf cramping. Skin: Reports right foot ulcer with yellow foul smelling drainage, and red streaking coming up the front part of his ankle along the inside portion of his calf muscle. VITALS Temperature is slightly elevated. Vitals are otherwise good. PHYSICAL EXAM CV: Edema and pain in calf. Bilateral palpable femoral and papiteal pulses are present. I do not recognize a palpable dorsalis pedis or posterior tibial pulse; however, they are present via Doppler. MSK: Examination of the right foot: The necrotic wound on his heel is present. It is approximately 2 cm x 2 cm. I do recognize the sloughing of the tissue, as well as what looks like cellulitis around the area, and erythema. An odor is present from the wound. I do not appreciate any bony exposure now. No pain to palpation in the effected area. RESULTS 3 views of the right foot were taken today. These reveal no evidence of osteomyelitis or infection. ASSESSMENT Right non-healing diabetic foot ulcer. Diabetes. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed. In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results. INSTRUCTIONS The patient will follow up with me in 7 days to check on his progress.

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

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

[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 Hematuria. Chronic urolithiasis. HISTORY OF PRESENT ILLNESS Mrs. Kelly Wood is a 41-year-old female established patient with chronic urolithiasis who returns in follow up for renal ultrasound due to hematuria. The patient reports having intermittent episodes of gross hematuria over the past several months. she states she had multiple voids in one day where the color of her urine was like cherry Kool-Aid last week; then passed 2 small stone like structures. Pain at the time was 8 out of 10 on a scale of 10. she currently denies any flank pain. CURRENT MEDICATIONS Alavert 10 mg tablet once daily. ALLERGIES No known drug allergies. PHYSICAL EXAM Genitourinary: Normal vaginal exam. RESULTS Renal Ultrasound Impression: Right kidney is 10 cm in length by 5 cm wide. There are no stones, masses, or hydronephrosis. The left kidney is 10.8 cm in length and 5 cm wide. There is a 6 mm left renal stone, non-obstructing. 533 ml pre void and 0 ml post void. Urine Dipstick without Micro Color: Yellow. Appearance: Clear. Leukocytes: Negative. Nitrate: Negative. Urobilinogen: 0.2 EU/dL. Protein: Negative. pH: 5.5 Blood: Trace, intact. Specific gravity: 1.020 Ketone: Negative. Bilirubin: Negative. Glucose: Negative. ASSESSMENT • Hematuria. • Chronic urolithiasis. Mrs. Wood presents today for renal ultrasound. The patient has had recurrent episodes of hematuria over the past few months secondary to chronic urolithiasis. Mrs. Wood reports passing two small stone like structures last week. Urinalysis today was notable for only a trace amount of blood and the renal ultrasound revealed a 6 mm non-obstructing renal stone in the left kidney. PLAN No surgical intervention is recommended, and the patient would like to discuss urolithiasis prevention. We had a very lengthy discussion with regards to urolithiasis formation and treating the underlying cause to prevent reoccurrence and associated potential dietary factors that could be involved with urolithiasis formation. It is recommended that the patient maintain a healthy diet; limit salt, and animal protein. she should increase fluid consumption; adequate intake is half of her body weight in ounces of water daily and avoid sugary drinks. A copy of the dietary recommendations and avoidances was provided to the patient for reference. We will continue to monitor annually with renal ultrasound unless new symptoms develop. The patient voiced understanding and agreed with the recommended medical treatment plan. INSTRUCTIONS Follow up in 1 year with renal ultrasound, sooner should symptoms arise. Should you develop sudden onset of severe pain or gross hematuria go to the emergency room.

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

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.

[doctor] patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable . [doctor] worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . 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 lo- are noted . [doctor] hello , mr . ward . nice to meet you . i'm dr. flores . [patient] hi , doc . nice to meet you . [doctor] i was just reviewing your records from dr. howard and he's referred you because the workup for headaches revealed a mass on your pituitary gland . i did review your mri images and you have a significant mass there . can you tell me about the issues you've been experiencing ? [patient] yeah sure . so i'm really getting fed up with these headaches . i've been trying my best to deal with them but they've been going on for months now and i'm really struggling . [doctor] where are the headaches located and how would you describe that pain ? [patient] located behind my eyes . it's like a dull nagging ache . [doctor] okay . was the onset gradual or sudden ? [patient] well it started about three months ago . and they've been getting worse over time . at first it was like three out of 10 severity , and it just gradually worsened . and now it's about six out of 10 severity . the headaches do tend to be worse in the morning and it feels like a dull ache behind the eyes . they last a few hours at a time , nothing makes them better or worse . [doctor] okay . can you tell me if the pain radiates , or if you have any other symptoms ? specifically feeling sick , fever , rashes , neck stiffness , numbness , weakness , passing out ? [patient] no . i have n't been sick or felt sick . ca n't recall a fever or any kind of rash . no- no neck issues , no numbness , no tingling . and i've never passed out in my life . but , um , for some reason recently i seem to be bumping into door frames . [doctor] okay . have you noticed any change in your vision or with your balance ? [patient] no i do n't think so . my eyes were checked in the fall . [doctor] okay . let's see , do you have any other medical problems that you take medicine for ? [patient] no i do n't have any medical problems and i do n't take any medicines . i tried tylenol a few times for the headaches but it did n't work , so i stopped . [doctor] i see . anyone in your family have any history of diseases ? [patient] i was adopted so i really have no idea . [doctor] okay . um , what kind of work do you do ? and are you married ? [patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house . [doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ? [patient] nope . i do n't do any of those and never have . [doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done . [patient] sounds good , doc . [doctor] all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . visual field testing reveals bitemporal hemianopia . and color vision is normal . [doctor] all right , mr. ward . i'm going to review these pictures from the mri with you . um , now this appears to be a benign pituitary adenoma , but there's no way to be sure without sending the removed adenoma to pathology to make the diagnosis , which we will do . um , here you can see it's a well defined mass . and it's pressing right here on what we call the optic chiasm . and today when i was having you look at my fingers , you could n't see them off to the sides , that's what we call bitemporal hemianopia . and explains why you have been bumping into door frames . [patient] yeah i never noticed that i could n't see out of the side until you did that test , and you closed one eye with both eyes . i really could n't tell . [doctor] no because you're having this vision loss from the mass compressing the optic chiasm , the only option we have is to do surgery . [patient] okay , i understand . do you think i'll regain my vision ? [doctor] well there's no guarantees , but it is a possibility . i'm gon na refer you to the eye doctor for a full exam and they'll do what's called visual field test . this will map our your peripheral vision or side vision prior to surgery . and we can monitor after surgery to see if your vision is improving . [patient] all right . [doctor] and let's discuss the surgery a little more . um , we would do what's called a transsphenoidal approach to do the surgery . this is minimally invasive and we go through the sphenoid sinus . there are some risks i have to inform you of . uh , risk of anesthesia including but not limited to the risk of heart attack , stroke , and death . risk of surgery include infection , need for further surgery , wound issues such as spinal fluid leak or infection , uh , which may require long , prolonged hospitalization or additional procedure . uh , seizure , stroke , permanent numbness , weakness , difficulty speaking , or even death . [patient] well i guess we have to do it regardless . [doctor] okay . so i will have you see our surgery scheduler , deborah , on the way out to get you set up . we will get this scheduled fairly quickly so i do n't want you to be alarmed . um , she'll also get you set up today or tomorrow to have the visual field test and you may not be able to see the eye doctor until after surgery . but we have the pre-surgery visual field test for comparison after surgery . [patient] okay . i look forward to these headaches going away . i never thought it could be something like this going on . [doctor] yeah . come this way , we'll get your things lined up . please call if you think of any questions . [patient] thanks , doctor . [doctor] diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note .

CHIEF COMPLAINT Left knee pain. HISTORY OF PRESENT ILLNESS Andrea Barnes is a 34-year-old female who presents today for evaluation of left knee pain. The patient has been experiencing intermittent episodes of pain and sudden instability with ambulation. Her pain is localized deep in her patella and occurs less than once daily. Due to the fleeting nature of these episodes, she has not taken medication and simply braces herself until it passes. She denies any trauma or injury, or ever hearing or feeling a pop in the knee. Her symptoms do not interfere with her daily activities and she does not use a cane. Regarding her hypertension, it has been several days since she last checked her blood pressure at home, but it was approximately 120/70 mmHg at that time. Her current medications include amlodipine, lisinopril, and hydrochlorothiazide, all of which she takes on a regular basis. In terms of her diabetes, her fasting morning blood glucose levels have been approximately 130 based on home monitoring. This is slightly higher than usual, even though she has been compliant with metformin and Farxiga. She does try to avoid eating late at night. MEDICAL HISTORY Patient reports a personal history of hypertension and type 2 diabetes. SOCIAL HISTORY Patient likes to travel and is planning a trip to Columbus, Georgia in the next month or so. She is part of the Lion's Club. MEDICATIONS Patient reports that she is taking amlodipine, lisinopril 20 mg once daily, hydrochlorothiazide, Metformin, and Farxiga. REVIEW OF SYSTEMS Musculoskeletal: Reports left knee pain and instability, VITALS Temperature: 98.2 degrees F Heart rate: 72 bpm Respirations: 16 Blood pressure: 122/70 mmHg PHYSICAL EXAM MSK: Examination of the right knee: No ecchymosis or edema. No effusion. No pain with palpation. Examination of the left knee: Full range of motion. Negative varus and valgus stress test. RESULTS X-rays were obtained and reviewed today. These reveal no evidence of fracture or bony abnormality. ASSESSMENT 1. Left knee pain. 2. Hypertension. 3. Diabetes mellitus type 2. PLAN After reviewing the patients x-rays, I believe there is some arthritis in the knee. I'm going to prescribe meloxicam 15 mg once daily. We can consider physical therapy to strengthen the muscles around the area to prevent any further issues. Her hypertension is well controlled with her current medication regimen. She can continue with lisinopril 20 mg once daily. I'm also going to order an echocardiogram for further evaluation of the murmur heard on exam. She has been compliant with metformin as prescribed, but her blood glucose levels have been slightly elevated recently. I'm going to order a lipid panel, as well as a hemoglobin A1c to determine if any adjustments need to be made to her dose of metformin.

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

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

[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 .

CC: Right arm pain. HPI: Ms. Martinez is a 43-year-old female who presents today for an evaluation of right arm pain after she hitting her arm on a pole while playing tennis. She had mild swelling at the time. There is pain with motion. She denies any numbness or tingling in her hand. She has a past medical history of allergies and takes Flonase. EXAM Examination of the left wrist shows tenderness over the distal radius and pain with flexion of the wrist and thumb. RESULTS X-rays of the left wrist show no obvious signs of acute fracture or other abnormality. IMPRESSION Right wrist sprain. PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and anti-inflammatory medications. I am prescribing Motrin, 800 mg to take 3 times a day with food. She will follow up with me in 1 week or as needed.

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

CHIEF COMPLAINT 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.

[doctor] mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool app that i'm using that's gon na help me focus on you a bit more would that be alright with you [patient] yeah that sounds great [doctor] okay great so mark tell me about your right elbow pain what's been happening [patient] so yeah i've been playing a lot of tennis recently buddy of mine you know you're always telling me to get off the couch and be more active so a buddy of mine asked me if i wanted to go play tennis he just joined a country club i've been hitting hitting the cord a lot more and it's just been killing me for the last three weeks or so [doctor] okay alright and where in your elbow is it hurting [patient] outside part [doctor] hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else [patient] no it does n't [doctor] okay and what would you say the pain is you know on a scale of zero to ten [patient] it's probably an eight when i'm just when i'm using it even if it's to get something out of the cupboard and it's a three when i'm just kinda resting [doctor] hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it [patient] all of the above shooting stabbing very sharp [doctor] okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you [patient] not that i can recall [doctor] okay and and you said it's it's worse with movement better with rest is there anything else that makes it makes it worse or makes it better [patient] i've taken some tylenol and ibuprofen but as soon as those wear off it it comes right back so they do n't really help [doctor] okay [patient] and i did try a little ice i probably should ice it more but i did n't notice it helping much [doctor] okay okay alright yeah well i definitely i'm glad you're getting some exercise now that's good for your diabetes and all that and out there playing tennis kinda back back to the back to the old days for you right did do i recall that were n't you a big tennis player back in the day like state champ in high school or something [patient] yeah yeah that was a hundred years ago i ca n't i i try to play like that and i ca n't i ca n't do that anymore but yeah a good memory that's a that's a good memory [doctor] now [patient] kind of a tennis guy too right did you see the the australia open [doctor] i did i did yeah that was that was crazy that was a great tournament what a what a finish unbelievable [patient] yeah hey did you see the masters i know you're a golfer [doctor] yeah yeah yeah i do n't get out as often as i as as i like to but but the masters yeah that was that was amazing that was lot of fun to lot of fun did you catch it too [patient] i did [doctor] yeah [patient] yeah [doctor] yeah [patient] but that's it was i i could n't believe tiger went out there of course he did [doctor] right [patient] it was cool to see nothing [doctor] yep yep agreed agreed and so well listen we'll we'll hopefully get you feeling better here and get you back out on the court and out on the course and we'll talk about that but let's let me ask you about your diabetes a little bit a little bit here so how have your blood sugars been running mark have they been what in the low one hundreds two hundreds where are they [patient] they are like one fifty one sixty you know we just had easter and my kids got a whole bunch of candies so i keep eating that [doctor] hmmm okay yeah yeah understood so those cadboy eggs they'll get you every time too right [patient] yes [doctor] boy my gosh yeah those are the best so those are those are deadly do n't tell my cardiologist so okay so listen you know i see that we have you on metformin five hundred milligrams once a day no actually last visit we increased it so i've got you on metformin five hundred milligrams twice a day correct you're still taking that [patient] yes twice a day [doctor] okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed [patient] yeah knock on wood i my asthma is pretty much under control [doctor] okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct [patient] that's correct yes [doctor] okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct [patient] yes that's right [doctor] okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you [patient] kills [doctor] okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you [patient] yeah it hurts a little bit [doctor] okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joint effusion and otherwise it's a normal right elbow x-ray so that's reassuring okay and hey you know i meant to ask you you know and do you have any history of fever recently you know along with the elbow pain you had noticed a fever [patient] no i do n't think so [doctor] okay great excellent alright so tell you what let's let's talk about my assessment and your plan here so for your first problem my assessment is is that you have acute lateral epicondylitis of your right elbow and this is also known as tennis elbow go figure right so this is due to overuse likely the increase in your your tennis activity which normally would be good but maybe we're overdoing it a little bit so i have a few recommendations i'd like you to rest your right arm as much as you can i want you to stop tennis for the next four to six weeks and please avoid repetitive stress in that right arm as well i want you to ice that right elbow for twenty minutes at least three times per day and this should reduce the pain and inflammation and then i'm also going to give you a brace for your right forearm and my nurse will give this to you before you leave that should help with the discomfort okay in that right elbow i will also write you a prescription for ultram and this should help with the pain i'll write you a prescription ultram fifty milligrams once per day that should help with your elbow pain so then i wan na see you in follow-up in four weeks and so we'll reevaluate your elbow at that time and if you we'll consider some additional imaging if needed possibly a physical therapy referral depending on how you're doing mkay now for your second problem of diabetes type two my assessment is is that your blood sugar is a little bit out of control mkay so we need to make some adjustments i'm going to increase your metformin to one thousand milligrams twice per day and i want you to check your blood sugar twice daily for the next two weeks and then let me know how your blood sugar is running and we can make some additional adjustments if needed but i will increase your metformin to one thousand milligrams twice a day now i'm going to also order a hemoglobin a1c level and and a cbc blood test today and and so we'll check those results the hemoglobin a1c and the cbc and then i'm going to also check a chem-12 blood test as well and now for your third problem of the mild acute intermittent asthma you my assessment is that it really remains under good control so let's keep you on that flovent and the albuterol no changes there and you can use those as tolerated it does look like you need a refill on your albuterol so i'm gon na write you a prescription for a refill of the albuterol and you can pick that up at your pharmacy as well so how does that all sound any questions for me [patient] it sounds pretty good i ca n't believe it's just tennis elbow feel like a looser coming in here but it's okay i get it [doctor] yeah yeah well [patient] i'm not i'm not young anymore [doctor] yeah well let's let's keep you active but take a break for a bit and let's ease back into it okay so it's great to see you and i'll see you back in four weeks let me know if you have other problems in the meantime [patient] okay

CHIEF COMPLAINT Cough. MEDICAL HISTORY Patient reports a history of rheumatoid arthritis. He denies any previous history of lung infections or pneumonia. SOCIAL HISTORY Patient reports he stopped smoking tobacco 7 years ago and has felt better since doing so. He notes that he enjoys biking. FAMILY HISTORY Patient reports his mother has a history of breast cancer, but is doing well. He denies any family history of lung cancer. MEDICATIONS Patient reports taking methotrexate 7.5 mg every week. REVIEW OF SYSTEMS Respiratory: Denies cough or shortness of breath. VITALS Blood Pressure: 124/76 mmHg. Heart Rate: 70 beats per minute. Respiratory Rate: 16 breaths per minute. Oxygen Saturation: 98% on room air. Body Temperature: Afebrile. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear and equal bilaterally. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No clicks, rubs, or murmurs. Pulses are intact in all extremities. Musculoskeletal - Examination: No lower extremity edema. Mild swelling to the 3rd digit knuckles on the bilateral hands, consistent with RA. Integumentary - Examination: Skin is pink, warm, and dry. Capillary refill is brisk. RESULTS CT scan of chest, obtained at an outside facility, is reviewed today and demonstrates a solitary 2 cm nodule in the lateral aspect of the right upper lobe. It appears the nodule is smooth in appearance. No evidence of any type of emphysematous disease is present. ASSESSMENT AND PLAN 1. Right upper lobe lung nodule. - Medical Reasoning: The patient has incidentally found right upper lobe lung nodule visible on his chest CT. It could be a benign nodule, but because of his smoking history, I think it is best that he has it surgically removed. - Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. Surgery will require general anesthesia and will take approximately 1.5 hours. I explained to the patient that his procedure will consist of 3 small incisions being made on the side of his right chest. I will then insert a camera and scope to assist in removing the nodule along with a very small portion of his lung. He was advised that he will be admitted for most likely an overnight stay. He will have a chest tube in until the following day when I remove it at his bedside. All questions were answered. - Medical Treatment: Pulmonary function test ordered today to obtain patient's baseline. PET CT will also be scheduled to determine if the nodule is metabolically active, which can suggest if it is cancerous or inflammatory. Nodule will be removed via video assisted thoracoscopy. 2. Rheumatoid arthritis. - Medical Reasoning: Stable. - Patient Education and Counseling: I encouraged the patient to continue to follow up with his rheumatologist. - Medical Treatment: Continue medication therapy and routine follow up with rheumatologist as previously outlined. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

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

CHIEF COMPLAINT Right-sided facial pain. REVIEW OF SYSTEMS Eyes: Denies vision changes or weakness in right eye. HENT: Reports right sided facial pain. Denies left sided facial pain. Neurological: Reports headaches. Denies sensory loss, numbness, or tingling in the right cheek. Denies right sided facial weakness. PHYSICAL EXAM Neurological - Orientation: Light touch testing of the right side of the face reveals numbness when compared to the contralateral side. Pinprick testing is sharp on the left side of the face; dull on the right side of the face. Ears, Nose, Mouth, and Throat Bilateral finger rub test is negative. - Examination of Mouth: Teeth are symmetric. RESULTS MRI of the head is reviewed today. This demonstrates a small blood vessel that is abutting, and perhaps even pinching, the right trigeminal nerve. ASSESSMENT AND PLAN 1. Trigeminal neuralgia. - Medical Reasoning: The patient has been experiencing facial pain for 2 to 3 months. A recent MRI revealed a small blood vessel abutting, or perhaps even pinching, the right trigeminal nerve. The root cause of his facial pain is the compression of the blood vessel against this nerve. - Patient Education and Counseling: The patient and I discussed treatment options including medicating with gabapentin or Tegretol. I explained the common side effects associated with these medications can include memory loss, tingling, and imbalance. We discussed the need for genetic testing due to the possible side effect of dermatologic reactions in people of East Asian descent. We also briefly discussed surgical treatment to decompress the nerve, but this is not recommended at this time. - Medical Treatment: A prescription for Tegretol will be sent to the patient’s pharmacy. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up with me in 1 month. If at that time his facial pain persists, we may further discuss surgical options.

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

HISTORY OF PRESENT ILLNESS Larry Garcia is a pleasant 41-year-old male who presents to the clinic today for the evaluation of back pain. The onset of his pain began 2 years ago, after moving furniture. He denies any specific injury. The patient describes his pain as sharp and stabbing. He locates his pain to his lower back, which radiates distally into his right leg and occasionally into his great toe. Sitting will increase his pain and he notes he is unable to get comfortable. The patient also reports numbness and tingling, especially in his right leg that radiates distally to his foot. He adds that he tries to be as active as he can, however it has been difficult with his back pain. The patient adds that he has gained weight over the past year. He denies any loss of sensation in his genital or rectal area, weakness, or loss of bladder or bowel control. In the past, he has attended physical therapy. The patient has also been prescribed pain medications, however they only provided temporary relief. He would like to avoid any surgical procedure at this time. SOCIAL HISTORY He quit smoking 20 years ago. FAMILY HISTORY The patient denies any family history of spine conditions. REVIEW OF SYSTEMS Constitutional: Reports weight gain. Musculoskeletal: Reports lower back pain. Neurological: Positive for numbness and tingling in the right leg and foot. Denies loss of bowl or bladder control, or loss of sensation in the genital or rectal area. VITALS Vitals are within normal limits. PHYSICAL EXAM NEURO: Decreased sensation to light touch at the right lateral thigh at the L4 dermatome. Patellar and Achilles reflexes are symmetrical. MSK: Examination of the lumbar spine: No overlying erythema or ecchymosis. Midline tenderness at L4-5 disc space with right-sided lumbar paravertebral tenderness. Pain with lumbar flexion. Supine straight leg test is positive. RESULTS The MRI of the lumbar spine was reviewed today. This revealed a disc herniation with nerve impingement. ASSESSMENT L4-5 herniated disc with radiculopathy. PLAN After reviewing the patient's examination and MRI findings today, I have discussed with the patient that his symptoms are consistent with an L4-5 herniated disc with radiculopathy. I have recommended that we treat the patient conservatively with a corticosteroid injection under fluoroscopy. With the patient's consent, we will proceed with a cortisone injection into the lumbar spine today.

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

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

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

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