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[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 Tick bite. MEDICAL HISTORY Patient reports a history of arthritis, hypertension, and diabetes type 2. SOCIAL HISTORY Patient reports he enjoys spending time outside in the woods and working in the yard. He went hunting with his grandchildren a couple of weeks ago. MEDICATIONS Patient reports taking lisinopril 20 mg once a day and metformin 1000 mg twice daily most of the time. REVIEW OF SYSTEMS Constitutional: Reports general ill feelings. Denies any fever, chills, flu like symptoms, body aches, or trouble waking. Respiratory: Denies cough or shortness of breath. Musculoskeletal: Denies joint pain or problems with ambulation. Skin: Reports warmth on the right knee. Neurological: Reports headache. Denies dizziness. VITALS Blood Pressure: 122/70 mmHg. Heart Rate: 67 beats per minute. Body Temperature: 98.4 degrees F. PHYSICAL EXAM Neck - General Examination: Neck is supple without thyromegaly or lymphadenopathy. Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs. Musculoskeletal - Examination of the right knee: Erythema and edema as well as an area of fluctuance noted over the right patella. There is pain to palpation of the right anterior knee. Full range of motion. Integumentary - Examination: There is evidence of a bull’s eye rash over the right knee. RESULTS Patient's previous kidney function is within normal limits. ASSESSMENT AND PLAN 1. Tick bite. - Medical Reasoning: My concern is that he might have Lyme disease based on the presentation of his right knee. - Patient Education and Counseling: The patient and I discussed blood testing to determine if he does in fact have Lyme disease. I explained that Lyme disease can cause problems with other organs if not treated appropriately. We discussed that sometimes antibiotics need to be administered intravenously if oral antibiotics are not given early enough. We will see how he does with a course of oral antibiotics as I would like to avoid intravenous antibiotics. - Medical Treatment: Prescription for doxycycline 100 mg twice a day for 3 weeks provided. Lyme titer and Western blot will be obtained to determine if he has Lyme disease. 2. Hypertension. - Medical Reasoning: This is well-controlled at this time. - Patient Education and Counseling: The patient and I discussed that he is doing really well monitoring his blood pressure at home. - Medical Treatment: Continue lisinopril 20 mg once a day. Lipid panel ordered to assess his cholesterol levels. 3. Diabetes type 2. - Medical Reasoning: He is doing a good job managing his diabetes since his blood sugars are running in the 120s. I do not think we need to make any adjustments, but we will see what the hemoglobin A1c shows as that gives us an idea of what his blood sugars are doing on a long-term basis. - Patient Education and Counseling: We discussed that metformin can affect kidney function; however, his kidney function was last checked 2 months ago, and it has remained within normal limits. - Medical Treatment: Continue metformin 1000 mg twice a day. Hemoglobin A1c ordered. Basic metabolic panel ordered to assess kidney function. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[doctor] so bryan it's nice to see you again in the office today what's going on [patient] i was in my yard yesterday and i was raking leaves and i felt fine and then when i got into my house about two hours later my back started tightening up and i started getting pins and needles in my right foot [doctor] alright have you ever had this type of back pain before [patient] i had it once about three years ago but it went away after a day [doctor] okay and did you try anything for the pain yet did you take anything or have you have you tried icing [patient] put some ice on it and i tried two advils and it did n't help [doctor] okay does it get better when you're laying down sitting standing [patient] yeah i think the only thing that helped was a hot shower and it feels a little better when i sit [doctor] okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately [patient] i i i normally do n't do any physical activity [doctor] yeah i hear you i make a i make my husband do all the yard work too so alright let me take a look at that low back if if you bend over does that hurt [patient] it hurts a little bit when i bend over yes [doctor] okay how about when you stand back up [patient] no pain [doctor] okay so no pain on extension some pain on flexion how about when i push right here on your back [patient] yeah that hurts [doctor] okay so some pain to palpation right around the l5 can i have that [patient] what happens when family members chime in like i'm doing right now because i actually think it was it hurts more when he stands up because i've watched him bend over but it's when he stands up that it really hurts [doctor] okay and and what's your relationship [patient] partners [doctor] okay so your partner is here with you today and reports that he is also having pain when you are standing up [patient] i've spent so many times you know who i am [doctor] so that's right you always come in together have you noticed anything else partner when when he is [patient] i'm worried about it because he is you know his pain tolerance is so high and he would n't be saying anything if it really was n't a problem because it's not at all like last week when he thought about raking leaves but did n't actually rake leaves but then his back did n't hurt as much but this time it really hurts [doctor] okay so you think this is more of a long term injury [patient] no he was just thinking about it hurting when he thought about raking but it did n't [doctor] okay alright and have you noticed any any prior pain with with the back [patient] i do n't want to take this away you better go back to talking to him [doctor] that's alright let's see how it turns out okay so how about if you if i push down on both your feet like this can you push back up on my hands [patient] can you repeat that [doctor] if i'm pushing down on your feet can you push push your feet back [patient] i [doctor] alright so your dorsiflexion is normal looks like pulses are equal in all extremities you said you had a little bit of a tingling sensation in which leg [patient] that would be my right leg [doctor] okay so some tingling in your right leg alright so i know that you had an x-ray when you came in because we always do x-rays when we have our patients come in of your low back and everything looks normal from that perspective so for your back pain sounds like you probably sprained your low back so i what i want you to do is let's rest it i'm going to prescribe some meloxicam have you taken that before [patient] i have not taken meloxicam [doctor] alright so i'll prescribe that i'm also gon na prescribe some physical therapy i know you said you have n't been overly active and your partner reported the same thing for a long time so we might wan na get you into some pt and hopefully get you back back in shape get you some stretches that you can do and some exercises and then you know if it's not improving i want you to send me a message and we can possibly look into see if there is anything else going on potentially an mri if it's still not improving does that sound like an okay plan [patient] it sounds reasonable [doctor] alright [patient] i think he should have an mri now i think he had surgery yesterday i think he should have an mri now this it's been hurting for like six hours now and she had an mri we are really worried about it [doctor] alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving [patient] good answer [doctor] alright alright hope you feel better

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

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

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

CHIEF COMPLAINT Follow up. SOCIAL HISTORY The patient has been trying to limit his tobacco use for 2 years. He reports smoking once every week. MEDICATIONS Bumex 2 mg once daily. Cozaar 100 mg daily. Norvasc 5 mg once daily. REVIEW OF SYSTEMS Constitutional: Denies problems sleeping. Cardiovascular: Reports chest pain. Respiratory: Reports shortness of breath. Musculoskeletal: Reports bilateral ankle swelling. VITALS Blood pressure is 128/72 mm Hg. Other vital signs are within normal limits. PHYSICAL EXAM Neck - General Examination: No JVD Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular - Auscultation of Heart: 2/6 stable systolic ejection murmur Musculoskeletal - Examination: Lower extremities show trace edema. RESULTS An echocardiogram, obtained at an outside facility, was reviewed today. It demonstrates a preserved ejection fraction of 55%. Normal diastolic filling. Mild to moderate mitral regurgitation. ASSESSMENT AND PLAN 1. CHF. - Medical Reasoning: The patient’s recent epsiode resulting in the emergency room visit was likely caused by his dietary indiscretion and uncontrolled hypertension that we have been monitoring. - Patient Education and Counseling: I reviewed the echocardiogram results with the patient and discussed the importance of following dietary restrictions. I encouraged the patient to take his medication on a consistent basis. I advised him to purchase a scale to weigh himself daily. - Medical Treatment: He will continue Bumex 2 mg once daily. He was provided with a referral to a nutritionist in consultation for further assistance with his dietary requirements to lower his sodium intake. 2. Hypertension. - Medical Reasoning: This is currently uncontrolled. - Patient Education and Counseling: I explained the importance of taking his medication on a daily basis. I encouraged the patient to purchase a blood pressure cuff and track his blood pressures. - Medical Treatment: He will continue Cozaar 100 mg daily as well as the Norvasc 5 mg once daily. I will order a renal artery ultrasound for further evaluation. 3. Systolic ejection murmur. - Medical Reasoning. Stable. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient was instructed to call me if he gains 3 pounds in 2 days.

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

CHIEF COMPLAINT Shortness of breath. HISTORY OF PRESENT ILLNESS Lawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath. The patient states he has had some shortness of breath and mild leg swelling which he thinks has to do with eating some salty foods at some house parties recently. His shortness of breath is primarily with exertion such as walking up the stairs. This has been going on for about 10 days now. He woke from sleep once with shortness of breath about a week ago. He also notes discomfort lying flat in bed and musculoskeletal stiffness in the morning. He states that it takes him a little while to get up. Regarding his type 1 diabetes, he is using his insulin pump. He has been consistently monitoring his blood sugars during the working week, but notes that he checks less on the weekends, due to being busy. He is trying to avoid sugar but admits to an affinity for chocolate bars. Regarding his depression, he states that it has been a crazy year and a half. He has tried some natural solutions. In the summer, he did daily outdoor stretching, which was great; but now that the weather has changed, he needs to find some alternatives. He is not ready to try any medications. He denies suicidal and homicidal ideation. Regarding his GERD, he is taking his omeprazole. He has made some lifestyle modifications like cutting back on his red bull intake and other caffeine. Reducing his alcohol intake has been tough during the holiday season, but he is getting better about this. The patient denies chest pain, fever, chills, cough, and abdominal pain. REVIEW OF SYSTEMS • Constitutional: Denies fevers, chills.  Endorses fatigue. • Cardiovascular: Denies chest pain. Endorses dyspnea on exertion. • Respiratory: Denies coughor wheezing. Endorses shortness of breath.. • Musculoskeletal: Endorses lower extremity edema. • Psychiatric: Endorses depression. PHYSICAL EXAMINATION • Neck: No carotid bruits appreciable. No jugular venous distention. • Respiratory: Rales are heard bilaterally at lung bases. • Cardiovascular: 3/6 systolic ejection murmur. • Musculoskeletal: 1+ pitting bilateral lower extremity edema. RESULTS Chest x-ray did not show any evidence of airspace disease. Labs were all within normal limits, including the WBC. ASSESSMENT Lawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath. PLAN Acute heart failure exacerbation. • Medical Reasoning: The patient is retaining fluid. He has noticed increased fluid retention following dietary indiscretion. He has experienced dyspnea on exertion for the past 10 days. • Medical Treatment: Initiate Lasix 40 mg a day. • Patient Education and Counseling: I advised the patient to monitor and log his daily weights. He will contact me if these continue to increase. He was instructed to call me or 911 if he experiences dyspnea at rest. Type 1 diabetes. • Medical Treatment: This is currently stable with use of an insulin pump. • Additional Testing: I will order a hemoglobin A1c in 1 month. • Medical Treatment: He will continue the insulin pump. The patient will follow up with his endocrinologist. • Patient Education and Counseling: I encouraged the patient to have an eye exam. Depression. • Medical Reasoning: The patient has been doing well with outdoor stretching. He continues to decline the use of medications for this issue. • Medical Treatment: I will refer him to psychiatry as his current management strategy is unsustainable due to the change in season. • Patient Education and Counseling: We will defer initiating medication at this time. Acid reflux. • Medical Reasoning: His symptoms are stable with medication. • Medical Treatment: Continue omeprazole 20 mg a day. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. his endo

[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 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] hey betty how are you doing [patient] i'm doing okay i just been really frustrated because with my asthma and it just seems like i can never catch a break never get better i'm always it seems like i'm always coughing and wheezing [doctor] i'm sorry to hear that what normally triggers your asthma type symptoms [patient] i find that it's really really when i get sick if i get sick with a cold i almost always know that my asthma is going to flare i did notice one time though that when i went to my aunt's house i i had a flare afterwards and i think it's because of her cat so i try to avoid going there and i have n't really had an issue since [doctor] okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems [patient] it seems like it happens really every month or every other month for the past six months i usually end up going to the urgent care a lot and get or my primary care doctor and so sometimes they'll give me antibiotics sometimes i'll get steroids one time it was so bad i actually ended up going to the emergency department [doctor] wow that that can be a little bit scary so you mentioned that your primary care provider or the urgent care provider gave you medications what medications are you using for your asthma right now [patient] i have two inhalers one but i really just use one of them it's a blue one that seems like the only inhaler that helps me the other one when i when i try to use it it does n't work [doctor] okay so do you think that's the albuterol inhaler is it do you remember the name like ventolin or [patient] yes yes that's the name of it [doctor] is that it okay alright and then how often do you feel like you need to use that [patient] i would say like almost everyday i feel like i'm using my inhaler because i'm always coughing and wheezing and a couple of times a night i'll wake up as a couple times a week i'll end up waking up needing to use my inhaler as well [doctor] okay and then when you use it at that time does it help [patient] it does [doctor] okay and how many walk me through how you use that you just wake up and you take one puff or is it two puffs [patient] yeah i take i usually take two puffs [doctor] okay but then you get enough relief that you can go back to sleep [patient] yeah for the most part [doctor] okay now have you ever needed to be hospitalized due to your asthma symptoms you mentioned you've had to go to the er [patient] yeah for only once i can think of when i was young i think like around eight years old i had to be hospitalized but nothing since then [doctor] okay i do wan na take a little bit of a a deeper dive here into your er and urgent care visits can you tell me a little bit more about those [patient] yeah i feel like i've had several i do n't remember the exact number but i've had several this past year they almost always have to start me on prednisone [doctor] okay like a prednisone taper pack that type of thing [patient] yeah yeah sometimes they'll just give me like like a like a large dose over five days [doctor] okay [patient] and then sometimes they make me take less and less and less so the over like nine or ten days [doctor] okay so both the dosepak and then also the high dose as well okay [patient] yeah [doctor] and then when was your last exacerbation [patient] probably about a month ago [doctor] okay so just out of curiosity you mentioned that you you have trouble when you go over to your aunt's house because of your cat now i see here that you really like to go outside and walk and do those type of things do you have any other type of issues whenever you you go outside any any seasonal allergies or anything like that [patient] no not really [doctor] okay so you do n't have any history of seasonal allergies which is good so it looks like here that you put down that you enjoyed hiking so you do n't have any trouble getting out and going hiking and and have you tried the new trails there behind behind the wreck center [patient] yeah i'm really excited to i mean i have to be careful because i you know with my coughing my wheezing but i'm really i'm looking forward to getting better so i can really start hiking again [doctor] okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis [patient] no i've never smoked and i do n't vape either or yeah i do n't smoke cigarettes or marijuana [doctor] okay and then you said you do n't vape so no vaping or e-cigarette use at all [patient] hmmm hmmm [doctor] okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that [patient] sometimes i go to the bars with some friends and yeah the smoking does irritate me [doctor] okay [patient] so i do n't try to go there often [doctor] okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam [patient] okay [doctor] now i reviewed your vitals for today and your your blood pressure is good it's one twenty eight over eighty two your respiratory rate is sixteen and your oxygen saturation is ninety nine percent on room air which is a good thing i'm gon na take a listen to your heart here your heart is regular rate and rhythm and i do n't appreciate any ectopic beats or and i do n't hear anything like rubs murmurs or gallops which is good so i'm gon na go take and listen to your lungs here on your lung exam i do appreciate some diminished lung sounds throughout with the occasional slight expiratory wheeze and that's bilaterally so i hear that on both sides i'm gon na go do a quick neck exam here neck is supple trachea is midline i do n't appreciate any lymphadenopathy taking a listen here i do n't appreciate any carotid bruit now i'm also gon na take a look at your hands here i note strong bilateral pulses i do n't appreciate any clubbing on any of your fingertips which is which is important and i also note brisk capillary refill i'm gon na go ahead and review the results of your pulmonary function test that i had you do when you came into the office today and reviewing those results i do see that they are consistent with somebody who would be diagnosed with asthma so lem me go ahead and tell you a little bit about my assessment and plan so now for your first problem of asthma your symptoms are consistent with moderate to intermediate or i'm sorry moderate moderate intermittent asthma and it's gon na be really important for us to be consistent with your inhaled inhaled steroid inhaler so i'm gon na need you to take that as prescribed and that's really gon na help cut down on those daily symptoms and needing to use that rescue inhaler that albuterol inhaler as frequently so the more you take and more consistently you take your inhaled steroid inhaler the less you will use your albuterol now it's not a fast acting inhaler like your albuterol but what is important is as going to be what helps you long term now if you do have an acute exacerbation so if you're having an acute issue with your breathing i do want you to continue to use your albuterol inhaler one to two puffs and then i want you to wait and see how your breathing is before you would take an additional one to two puffs we hope you have less of those acute exacerbations as you continue to use your inhaled steroid i'm also going to put together an asthma action plan for you and that's gon na help us look at your symptoms see where your your pain points can be you know like those being having issues with with cats or dust that type of thing and we'll work on how to handle those symptoms through that asthma action plan so do you have any questions comments or concerns otherwise i will see you in thirty days [patient] alright thank you [doctor] you're welcome [doctor] so let me tell you a little bit about my assessment and plan for your first problem of asthma your symptoms are consistent with moderate intermittent asthma i'm gon na start you on flovent one hundred ten micrograms one puff twice per day that's gon na be important for you to be consistent with your inhaled steroid inhaler this is gon na help prevent those daily symptoms and from needing for you to use your albuterol inhaler or that rescue inhaler less frequently you can continue using your ventolin inhaler and that would be two puffs every four to six hours p.r.n . i'm also gon na put together an asthma action plan for you so we know what to do based on your symptoms i'd like to see you again in a month or sooner if you have any worsening symptoms does that sound okay [patient] it does thank you [doctor] you're welcome i'll see you in a month [patient] alright thanks

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

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

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

[doctor] hey william so i see that you injured your knee could you tell me a bit about what happened [patient] yeah i thought it was a good idea to go to the trampoline park with my wife and heard a snap and instant pain when i was on the trampoline [doctor] okay alright and so do do you go to the trampoline park often [patient] i do n't and i think that's the issue [doctor] okay so this is the first time you'd ever done something like that [patient] yes [doctor] okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class [patient] no it's just for fun [doctor] okay and do you have like a regular exercise regimen at all [patient] try to not consistent with it [doctor] okay no that's fine this is not a place of judgment i just i'm just trying to understand like if a little bit more of the background okay so we went to the trampoline park which knee where did you hurt [patient] my right [doctor] okay your right knee and so based on like your inside and outside which part hurts more [patient] it's kind of the outside of the knee [doctor] alright so the lateral aspect not a problem and you said that you heard a pop when you landed right [patient] yeah [doctor] okay have you taken anything for the pain [patient] just tylenol [doctor] alright so did the tylenol help [patient] not really [doctor] okay alright and so hmmm when does it have you tried anything else like did you ice it use heat anything like that [patient] no i just kinda elevated it and that was about it [doctor] okay that's fine and how long ago did this happen [patient] a week ago [doctor] okay alright so you put up with the pain for a week that's i'm proud of you for that [patient] i do n't like to come to the doctors [doctor] excuse me i feel rejected right now why why would you say something like that it's fine but you know i i like it when you're not here either because that means that you're doing a good job so let's see about like getting your knee fixed up but i want to talk about some of the other issues that you have first so we know that you have hypertension right and i discussed maybe you getting a blood pressure cuff because i needed you to measure those a bit more regularly did you get the cuff [patient] what no [doctor] no okay that's fine have you measured your blood pressure recently at all [patient] no [doctor] okay are you still taking your medication because i see you're on twenty milligrams of lisinopril [patient] yeah most days i remember [doctor] okay [patient] ra i'm not suspicious but we're just gon na go with that okay because looking at your vitals it it is of still a bit high i'm not really comfortable i see like a hundred and eighty over you know eighty and [doctor] that's not where we wan na be so i wonder if we might need to adjust your medication but let's talk about your diabetes how are your blood sugars [patient] i think they're little bit better [doctor] okay what makes you think that have you been taking them [patient] yeah i check it you know most days again kinda when i remember [doctor] okay how often are you checking it [patient] i would say four five times a week [doctor] okay you might wan na switch to maybe two or three times a day but you know that's something i'm glad that you are measuring are you taking your metformin [patient] yes [doctor] okay and then i think we have you on five hundred milligrams correct [patient] yes [doctor] alright how is your diet [patient] kinda the same as my exercise decent could be better [doctor] alright and okay not a problem so what is your do you are you measuring your calories at all looking at your macros are you just eating what you feel like [patient] yeah just trying to watch what i eat more than anything but nothing specific [doctor] okay and are you do you know if you're particularly focused on your salt like is it like a low salt diet [patient] no just trying to watch my carbs a little bit more but not counting or anything [doctor] alright so like is it a specific diet i just wan na make sure like are you on like the keto diet [patient] no [doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally i would like to look at your knee though so when i press here on the outside does it hurt [patient] little bit [doctor] okay and then when i press on the inside does it hurt [patient] no [doctor] alright can you bend your knee and straighten it [patient] i can i think that's all i can i can bend [doctor] mm-hmm alright so are you having problems walking can you bear weight [patient] i can but i have a little bit of a limp [doctor] okay so do you mind getting up and walking for me really quickly alright so i do notice that there is a slight gait like there is a small sorry you are correcting you do have a limp i i am a little worried about that but it's probably it's probably the superficial when i'm looking at your knee i do notice some like ecchymosis and edema that just means bruising and swelling along the lateral aspect of your knee i do n't notice any effusion and it looks like you have a decent range of motion but i do understand that you know you are experiencing pain with some movement okay i'm gon na go ahead and order an x-ray and when you come back we can have that discussion alright so i reviewed the results of your right knee x-ray which showed no evidence of fracture or bony abnormality so let's talk about my assessment and plan alright so for your first problem of right knee pain i think you have a lateral a lateral ligament strain i wan na prescribe some meloxicam which is gon na be fifteen milligrams daily for pain and swelling i'm gon na refer you to physical therapy to help strengthen the muscles around the area and to prevent further injury if you're still having pain we can do further imaging imaging but like this is a common injury that tends to heal on its own for your second problem with hypertension i wan na continue the lisinopril at twenty milligrams and order an echo i am concerned that we might not be getting your blood pressure to where we need it to be so we might have to do some medication modification for your third problem with diabetes i wan na order an a1c i know that you said you have been measuring your blood sugars but i think this would give us a better image of what's been happening long term and i also wan na order a lipid panel in case we need to make any adjustments to that medication as well do you have any questions [patient] sounds good [doctor] alright awesome

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

CHIEF COMPLAINT Follow up. SOCIAL HISTORY The patient has been trying to limit his tobacco use for 2 years. He reports smoking once every week. MEDICATIONS Bumex 2 mg once daily. Cozaar 100 mg daily. Norvasc 5 mg once daily. REVIEW OF SYSTEMS Constitutional: Denies problems sleeping. Cardiovascular: Reports chest pain. Respiratory: Reports shortness of breath. Musculoskeletal: Reports bilateral ankle swelling. VITALS Blood pressure is 128/72 mm Hg. Other vital signs are within normal limits. PHYSICAL EXAM Neck - General Examination: No JVD Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular - Auscultation of Heart: 2/6 stable systolic ejection murmur Musculoskeletal - Examination: Lower extremities show trace edema. RESULTS An echocardiogram, obtained at an outside facility, was reviewed today. It demonstrates a preserved ejection fraction of 55%. Normal diastolic filling. Mild to moderate mitral regurgitation. ASSESSMENT AND PLAN 1. CHF. - Medical Reasoning: The patient’s recent epsiode resulting in the emergency room visit was likely caused by his dietary indiscretion and uncontrolled hypertension that we have been monitoring. - Patient Education and Counseling: I reviewed the echocardiogram results with the patient and discussed the importance of following dietary restrictions. I encouraged the patient to take his medication on a consistent basis. I advised him to purchase a scale to weigh himself daily. - Medical Treatment: He will continue Bumex 2 mg once daily. He was provided with a referral to a nutritionist in consultation for further assistance with his dietary requirements to lower his sodium intake. 2. Hypertension. - Medical Reasoning: This is currently uncontrolled. - Patient Education and Counseling: I explained the importance of taking his medication on a daily basis. I encouraged the patient to purchase a blood pressure cuff and track his blood pressures. - Medical Treatment: He will continue Cozaar 100 mg daily as well as the Norvasc 5 mg once daily. I will order a renal artery ultrasound for further evaluation. 3. Systolic ejection murmur. - Medical Reasoning. Stable. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient was instructed to call me if he gains 3 pounds in 2 days.

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

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

[doctor] all right . today i am seeing jose james . uh , date of birth 9/29/1957 . mr . james is a new patient who's having pain in his left shoulder and elbow . he fell five months ago going up a stairs , and the pain has been present since . [doctor] hi mr . james , i'm doctor isabella . how are you doing ? [patient] i'm okay . thank you . [doctor] that's good . that's good . tell me what's brings you in today . [patient] sure . so i've been having constant pain in my left shoulder and left elbow for a while , about five months or so . hurts all the time . pretty bad at times . [doctor] mm . that does not sound like fun . it sounds like you injured it going up the stairs ? [patient] yes , that's correct . it was icy , and i have to walk up a flight of stairs to my house . i stepped and my feet just went out . fell on my left side . seems like my shoulder and wrist took the brunt . it's been hurting since . [doctor] yeah , that does seem like a likely cause of your symptoms . anything seem to make the pain worse ? [patient] well , i've always hit the gym and lifted weights . i've been trying to keep with my routine of two days a week , but it's been hard . the pain is worse when i lift , and i have n't been able to lift more than 15 or 20 pounds which is very frustrating . [doctor] mm-hmm . i can imagine it is when you're so accustomed to your routine . [patient] exactly . i really enjoy my exercise , but over the past one to two weeks , i've stopped hitting the gym because the pain just was n't worth it honestly . i do keep up with my walking , though . my wife and i walk about 30 minutes almost every day . we have done this since i retired from my office job last year . [doctor] i do not blame you , mr . james . does anything seem to help the pain that you've tried ? [patient] not too much . i have iced a bit , but i have not taken anything for the pain . stopping exercise and some ice has helped a bit , but it still hurts enough for me to come to see you . [doctor] yeah , okay . how about any numbness or tingling ? have you felt that at any point ? [patient] no , doc . just pain . no tingling or numbless , numbness , thankfully . [doctor] understood . understood . all right . well , let's go ahead and take a look and see what's going on . [patient] sounds good . thank you . [doctor] okay . use my general physical exam template . mr . james , i'm going to gently press around your shoulder and elbow here to see where your pain might be stemming from . just let me know when it hurts . [patient] okay . it hurts when you press there on my elbow and here on my shoulder . [doctor] okay . left shoulder and elbow , tender sa space , no warmth , erythema or deformity . positive hawkins-kennedy and neer's test . normal proximal and distar , distal upper extremity strength . intact median radial ulnar sensation and abduction to 90 degrees . normal empty tan , can test . okay , mr . james , w-what i think you are dealing with is impingement syndrome of your left shoulder . i do n't think there's an additional injury or issue with your wrist , but because everything is connected , you're experiencing pain in your wrist because of your shoulder . we do see this type of issue when someone has a fall , so it's good you came to see us , you came in to see us so we could help . [patient] so what are the possible treatments ? [doctor] well , we have a few options you can try . first option would be to start with physical therapy . i would recommend two sessions per week as well as any other exercises they give you to do at home . we can start there and if that does n't improve your pain , then we could try a cortisone injection . [patient] i like the idea of starting with the physical therapy and have a next step if it does n't help . i am not opposed to a shot but would like to try the therapy first . [doctor] all right . great . i'll get a referral order , and they will call you within the next day or two to get you scheduled . [patient] okay . [doctor] mm-hmm . also , please continue to ice , especially your shoulder , and rest as much as you can . [patient] okay . i will . [doctor] give us a call or email us if you have symptoms worsen , if your symptoms worsen or do not improve with the therapy . [patient] will do . thank you . i appreciate your help . [doctor] you're welcome . have a great day . [patient] you too . [doctor] all right . assessment is impingement syndrome of left shoulder . plan discussed with patient . referral is requested for dr. martha rivera to be in physical therapy two days per week .

CHIEF COMPLAINT Cough, nasal congestion, and rhinorrhea. HISTORY OF PRESENT ILLNESS Randy Gutierrez is a 9-month-old male who is being evaluated today for a cough, nasal congestion, and rhinorrhea. He is accompanied by his mother. Symptoms began yesterday around dinnertime with clear nasal drainage, pulling on his ears bilaterally, and rubbing his nose frequently. He does not have a barky cough or a sore throat. His rectal temperature was 100.3 degrees. The patient did consume a 7 ounce bottle this morning, but mostly denied the next offered bottle and declined cereal. He is irritable and having trouble falling asleep, described “like he is fighting it”. The patient has been exposed to an older sister who is sick and a cousin who has a sinus infection. Treatment has included saline nasal spray, Tylenol, baby Vick's, and a humidifier. When the patient aroused this morning, he was warm to the touch. When his sleeper was removed, he was quite sweaty despite the air conditioner being on. The patient's dandruff is also worsening. The only tried treatment is Aveeno shampoo. SOCIAL HISTORY Older sister. CURRENT MEDICATIONS Tylenol PRN. PHYSICAL EXAM Temperature 100.3 degrees. Ears, Eyes, Nose, Throat Nasal congestion, clear mucus, rhinorrhea. Bilateral pulling of ears, no sore throat or hoarseness. Respiratory Positive for cough. ASSESSMENT • Viral infection • Dandruff PLAN Viral infection The patient presents with a viral infection and does not need antibiotics currently. I advised continuation of fluids, rest. Additionally, I suggested trying Zarbee’s for children under 1 years old. If a croup cough develops, the patient will receive a 0.5 teaspoon. I also provided counseling to the mother to avoid giving honey to the patient for his first year of life due to botulism spores. Dandruff The patient is experiencing worsening symptoms of dandruff. I recommended Head and Shoulders shampoo, Selsun Blue, or Nizoral A-D 2 times per week, combined with his usual shampoo. I counseled the mother that she should be careful not to get the shampoo in the patient eyes and to not use the extra strength shampoos. Additionally, he may also use baby oil and a soft brush on the area. INSTRUCTIONS Return in one week for a re-check.

[doctor] hey lawrence . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ? [patient] uh , i , i've noticed that i've been swelling up a little bit . i think a lot of it has to do with going to some house parties , eating some salty foods . i feel really lethargic . [doctor] okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ? [patient] it's something like walking up a flight of stairs i'll actually feel it . [doctor] okay . all right . now , um , how long has this been going on for ? [patient] probably about 10 days . [doctor] okay . all right . and you said you're noticed some swelling in your legs ? [patient] a little bit . [doctor] okay . do you have problems lying flat in bed ? [patient] um , i'm a little uncomfortable when i wake up in the morning and i feel pretty stiff . and , and , like , it takes me a little while to adjust to walking when i get up . [doctor] okay . all right . do you ever wake up acutely short of breath at night ? [patient] um , it happened once , probably about a week ago , but it has n't happened since . so i have n't been that concerned about it . [doctor] okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump . [patient] mm-hmm . [doctor] um , are your blood sugars okay ? have you noticed a spike in them recently ? [patient] um , i have n't . i've been pretty good about monitoring it so i ... during the working week , i stay on top of that . but on saturdays or sundays we're so busy i forget to monitor it . but i have n't seen anything spike . [doctor] okay . and i remember your affinity for chocolate bars , so ... [patient] guilty as charged . i love chocolate bars . [doctor] okay . all right . so , in terms of your depression , how are you doing with that ? [patient] uh , it's been a crazy year and a half . um , i've tried some natural solutions . in the summer i did stretches outdoors every morning , which was great , but now the weather changed and , uh , you know , i've got ta find some alternatives . i'm not ready to try any medications just yet , so- [doctor] okay . [patient] . i'm open to some suggestions . [doctor] okay . we'll talk about that . [patient] sure . [doctor] and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole . [patient] mm-hmm . [doctor] you were making some lifestyle modifications , cutting back on your red bull and caffeine . [patient] yeah . [doctor] alcohol intake has been ... how's that been ? [patient] tough during the holiday season , but i'm , i'm better . [doctor] okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ? [patient] no . no . absolutely not . [doctor] okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath . [patient] mm-hmm . [doctor] any other symptoms ? chest pain , fever , chills , cough ? [patient] no . [doctor] um , belly pain ? [patient] no . [doctor] okay . let's go ahead . i want to move on to a physical exam . [patient] mm-hmm . [doctor] hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find . [patient] mm-hmm . [doctor] okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion . [patient] mm-hmm . [doctor] but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ? [patient] okay . [doctor] hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good . [patient] mm-hmm . [doctor] so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every day . [patient] mm-hmm . [doctor] if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911- [patient] mm-hmm . [doctor] . and go into the emergency room . you might need some intravenous diuretics . [patient] mm-hmm . [doctor] okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ? [patient] sure . [doctor] no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ? [patient] not at this point . [doctor] okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ? [patient] you got it . [doctor] hey , dragon ? finalize the notes ...

CHIEF COMPLAINT Tick bite. MEDICAL HISTORY Patient reports a history of arthritis, hypertension, and diabetes type 2. SOCIAL HISTORY Patient reports he enjoys spending time outside in the woods and working in the yard. He went hunting with his grandchildren a couple of weeks ago. MEDICATIONS Patient reports taking lisinopril 20 mg once a day and metformin 1000 mg twice daily most of the time. REVIEW OF SYSTEMS Constitutional: Reports general ill feelings. Denies any fever, chills, flu like symptoms, body aches, or trouble waking. Respiratory: Denies cough or shortness of breath. Musculoskeletal: Denies joint pain or problems with ambulation. Skin: Reports warmth on the right knee. Neurological: Reports headache. Denies dizziness. VITALS Blood Pressure: 122/70 mmHg. Heart Rate: 67 beats per minute. Body Temperature: 98.4 degrees F. PHYSICAL EXAM Neck - General Examination: Neck is supple without thyromegaly or lymphadenopathy. Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs. Musculoskeletal - Examination of the right knee: Erythema and edema as well as an area of fluctuance noted over the right patella. There is pain to palpation of the right anterior knee. Full range of motion. Integumentary - Examination: There is evidence of a bull’s eye rash over the right knee. RESULTS Patient's previous kidney function is within normal limits. ASSESSMENT AND PLAN 1. Tick bite. - Medical Reasoning: My concern is that he might have Lyme disease based on the presentation of his right knee. - Patient Education and Counseling: The patient and I discussed blood testing to determine if he does in fact have Lyme disease. I explained that Lyme disease can cause problems with other organs if not treated appropriately. We discussed that sometimes antibiotics need to be administered intravenously if oral antibiotics are not given early enough. We will see how he does with a course of oral antibiotics as I would like to avoid intravenous antibiotics. - Medical Treatment: Prescription for doxycycline 100 mg twice a day for 3 weeks provided. Lyme titer and Western blot will be obtained to determine if he has Lyme disease. 2. Hypertension. - Medical Reasoning: This is well-controlled at this time. - Patient Education and Counseling: The patient and I discussed that he is doing really well monitoring his blood pressure at home. - Medical Treatment: Continue lisinopril 20 mg once a day. Lipid panel ordered to assess his cholesterol levels. 3. Diabetes type 2. - Medical Reasoning: He is doing a good job managing his diabetes since his blood sugars are running in the 120s. I do not think we need to make any adjustments, but we will see what the hemoglobin A1c shows as that gives us an idea of what his blood sugars are doing on a long-term basis. - Patient Education and Counseling: We discussed that metformin can affect kidney function; however, his kidney function was last checked 2 months ago, and it has remained within normal limits. - Medical Treatment: Continue metformin 1000 mg twice a day. Hemoglobin A1c ordered. Basic metabolic panel ordered to assess kidney function. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

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

CHIEF COMPLAINT 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] 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 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] alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened [patient] well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then all of a sudden i'm here [doctor] hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath [patient] i did but i did n't think anything of it [doctor] sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on [patient] i have but i miss them every year and then so i think today i took one [doctor] okay alright yeah i have you on bumex cozaar and norvasc does that sound right [patient] i guess so that sounds about right [doctor] alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that [patient] i've just been eating anything honestly i try to watch it here and there but to tell you the truth i'd looks i was eating [doctor] yeah i i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or [patient] little bit of everything here and there i do lot of chips [doctor] sure [patient] they're pretty good i guess they're salty even though the light salt ones but [doctor] mm-hmm [patient] kinda whatever i can get my hands on really [doctor] okay alright how are you feeling right now [patient] i'm doing a little okay i guess i'm just out of breath a little bit but it's nothing i ca n't handle [doctor] sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those [patient] no i have n't got one yet i know i needed to get one [doctor] yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately [patient] just like i said when i was walking outside it helped a little bit but again i just walked it off [doctor] sure any problems sleeping [patient] no i sleep like a rock [doctor] good good to hear have you had any chest pain [patient] slightly here or there but i thought it was just heartburn [doctor] sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that [patient] i've been pretty good on it very once every week maybe just one [doctor] okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay [patient] that sounds good document [doctor] awesome weigh yourself daily do you have a scale at home [patient] no but i can get one [doctor] okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good [patient] that sounds good to me [doctor] great okay david do you have any other questions [patient] no other questions at this time just i guess i just need to make sure to take my medication on time that's about it [doctor] yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well [patient] i will do my best [doctor] alright thanks hope you feel better [patient] thank you

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.

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

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

[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] 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 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] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . [doctor] hello , how are you ? [patient] i'm good , thank you . [doctor] so tell me what brings you in today . [patient] recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic . [doctor] or how have you been feeling in general with this ? [patient] not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me . [doctor] okay . are there any other symptoms ? [patient] i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess . [doctor] sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ? [patient] yeah , i've been anemic since i was 13 years old . [doctor] right . so why do your doctors think you're anemic ? do you have a history of heavy periods ? [patient] well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly . [doctor] yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ? [patient] about five to six years ago . [doctor] and was it relatively a normal exam ? did you have any polyps ? [patient] no . they said they'd see me in 10 years . [doctor] well that's good news . [patient] yeah , i agree . [doctor] um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ? [patient] no . [doctor] all right . do you ever drink alcohol ? [patient] yeah , but only once or twice a year . [doctor] okay . are you taking any supplements such as iron or vitamin b12 ? [patient] i already started taking my iron pills which i have not taken in about a year . [doctor] all right . and what are you taking ? [patient] i'm taking 25 milligram tablets , twice daily . [doctor] okay , and that's the , the ferrous sulfate ? [patient] yeah , that's it . i take one in the morning and one in the evening . [doctor] okay . anything else ? [patient] yeah , i take vitamin b12 , just the over the counter stuff . [doctor] okay , very good . all right , well let's go ahead and take a look and see what's going on . [patient] sounds good . thank you . [doctor] of course . you'll hear me , uh , talk through your exam so that i get all the information documented . [patient] okay . [doctor] all right . so use my general physical exam template . i will start by listening to your heart and lungs . [patient] okay . [doctor] all right . next , i'd like you to lay back so i can examine your abdomen . [patient] okay . [doctor] is there any tenderness where i'm pressing ? [patient] no . [doctor] okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding . [patient] is that why they want me to have another upper endoscopy ? [doctor] actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why . [patient] lovely . [doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . [patient] okay . [doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . [patient] all right . [doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled . [patient] okay . [doctor] um , have you ever had any issue with sedation in the past ? [patient] no , i was just sleepy afterwards . [doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [patient] okay . sounds like a plan . [doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . [patient] okay , that sounds great . [doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you . [patient] thank you . [doctor] you're welcome . have a great day , have a great day ms. cooper . [patient] you too . [doctor] all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .

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

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

CHIEF COMPLAINT 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 .

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] so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle [patient] well we had a long spring and the other day we got some snow and ice i was walking to my car and i slipped and my left ankle kinda turned underneath me [doctor] okay and so this happened couple days ago or how many days ago [patient] two days ago [doctor] two days ago okay and so it's your left ankle and it kinda just twisted underneath you on the kind of on the inside [patient] yeah more on the it's more on the outside of my hips [doctor] and did you fall down or did you just kind of cut catch yourself [patient] no i fell [doctor] okay and were you able to get up afterwards or somebody helped you up [patient] i was but it was very sore and then started swelling and quite a bit of pain so it's hard to walk [doctor] sure have you tried anything for pain or the swelling or anything like that [patient] ibuprofen some ice and elevation [doctor] okay has that helped much or not really [patient] a little bit [doctor] okay and any pain above your ankle does it hurt on your on your calf or your lower leg at all or knee at all [patient] no it's mostly just the outside of my ankle [doctor] okay got it and no bleeding or i'm sure it's a little swollen probably [patient] yeah it's swollen but no bleeding [doctor] well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood sugars been how how're you managing that any issues with that [patient] no they've been pretty stable [doctor] okay [patient] so with my diet [doctor] good [patient] so [doctor] you're checking your sugars regularly as well [patient] yes [doctor] okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you seen the ophthalmologist recently for your eye exam for your diabetes checkup or no [patient] i am due for one of those in the next couple of weeks [doctor] okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that [patient] i have an appointment [doctor] perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything [patient] i need a refill on that yes [doctor] okay alright well let me examine you here for a second so i'm gon na go ahead and do my match exam and i'm just gon na verbalize some of my findings so i can put that into my record okay so your neck exam is fine there is no bruits your lungs are clear your heart exam is normal you do have a two over six systolic ejection murmur you had that in the past unchanged from before so that's not really worried about that your belly exam is good on your ankle exam on your left ankle you do have some tenderness over the lateral malleolus and you do also have some tenderness over this bone here which is the fifth metatarsal so i do n't see any there is some swelling there some redness but there is some pain with valgus stressing of your ankle as well and let me turn off my phone here and also you do have otherwise normal sensation normal pulses so on your so my diagnosis for your ankle is i think you probably have an ankle sprain but i would like to order an x-ray of your ankle because you do have some tenderness over this bone and i'm sometimes worried about a fracture so i'm gon na go ahead and get an x-ray i'm gon na put you in a splint we're gon na put you in a in an air splint and i'll give you some crutches until i get the x-ray back i want you to do just avoid weightbearing just to make sure there is no fracture there i will give you some naprosyn five hundred milligrams twice a day for pain control keep it elevated put some ice on it i think those are all good things and if the x-ray shows a fracture i'm gon na go ahead and give you a call back and we'll send you to orthopedics but right now let's try this air splint if there is no fracture i will probably have you take off the air splint and do some partial weightbearing and see how it goes does that sound like a reasonable plan for you [patient] that's a great plan i need to get back to exercising so [doctor] okay [patient] thank you [doctor] perfect and for the diabetes keep the eye appointment that you already have you know continue with the metformin i'm gon na order another hemoglobin a1c today we'll check some baseline labs as well since it's been a while since we checked them and then once if you have any issues or you know give me a call we can get you into the office and for the high blood pressure i'll go ahead and refill the norvasc today you're doing a great job with that it sounds like continue to monitor that if something changes certainly call me we can get you in sooner okay [patient] thank you [doctor] sounds good sounds good good great seeing you thanks stephanie [patient] thank you

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

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

[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 .

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

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

[doctor] so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle [patient] well we had a long spring and the other day we got some snow and ice i was walking to my car and i slipped and my left ankle kinda turned underneath me [doctor] okay and so this happened couple days ago or how many days ago [patient] two days ago [doctor] two days ago okay and so it's your left ankle and it kinda just twisted underneath you on the kind of on the inside [patient] yeah more on the it's more on the outside of my hips [doctor] and did you fall down or did you just kind of cut catch yourself [patient] no i fell [doctor] okay and were you able to get up afterwards or somebody helped you up [patient] i was but it was very sore and then started swelling and quite a bit of pain so it's hard to walk [doctor] sure have you tried anything for pain or the swelling or anything like that [patient] ibuprofen some ice and elevation [doctor] okay has that helped much or not really [patient] a little bit [doctor] okay and any pain above your ankle does it hurt on your on your calf or your lower leg at all or knee at all [patient] no it's mostly just the outside of my ankle [doctor] okay got it and no bleeding or i'm sure it's a little swollen probably [patient] yeah it's swollen but no bleeding [doctor] well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood sugars been how how're you managing that any issues with that [patient] no they've been pretty stable [doctor] okay [patient] so with my diet [doctor] good [patient] so [doctor] you're checking your sugars regularly as well [patient] yes [doctor] okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you seen the ophthalmologist recently for your eye exam for your diabetes checkup or no [patient] i am due for one of those in the next couple of weeks [doctor] okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that [patient] i have an appointment [doctor] perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything [patient] i need a refill on that yes [doctor] okay alright well let me examine you here for a second so i'm gon na go ahead and do my match exam and i'm just gon na verbalize some of my findings so i can put that into my record okay so your neck exam is fine there is no bruits your lungs are clear your heart exam is normal you do have a two over six systolic ejection murmur you had that in the past unchanged from before so that's not really worried about that your belly exam is good on your ankle exam on your left ankle you do have some tenderness over the lateral malleolus and you do also have some tenderness over this bone here which is the fifth metatarsal so i do n't see any there is some swelling there some redness but there is some pain with valgus stressing of your ankle as well and let me turn off my phone here and also you do have otherwise normal sensation normal pulses so on your so my diagnosis for your ankle is i think you probably have an ankle sprain but i would like to order an x-ray of your ankle because you do have some tenderness over this bone and i'm sometimes worried about a fracture so i'm gon na go ahead and get an x-ray i'm gon na put you in a splint we're gon na put you in a in an air splint and i'll give you some crutches until i get the x-ray back i want you to do just avoid weightbearing just to make sure there is no fracture there i will give you some naprosyn five hundred milligrams twice a day for pain control keep it elevated put some ice on it i think those are all good things and if the x-ray shows a fracture i'm gon na go ahead and give you a call back and we'll send you to orthopedics but right now let's try this air splint if there is no fracture i will probably have you take off the air splint and do some partial weightbearing and see how it goes does that sound like a reasonable plan for you [patient] that's a great plan i need to get back to exercising so [doctor] okay [patient] thank you [doctor] perfect and for the diabetes keep the eye appointment that you already have you know continue with the metformin i'm gon na order another hemoglobin a1c today we'll check some baseline labs as well since it's been a while since we checked them and then once if you have any issues or you know give me a call we can get you into the office and for the high blood pressure i'll go ahead and refill the norvasc today you're doing a great job with that it sounds like continue to monitor that if something changes certainly call me we can get you in sooner okay [patient] thank you [doctor] sounds good sounds good good great seeing you thanks stephanie [patient] thank you

CHIEF COMPLAINT Right-sided abdominal pain MEDICAL HISTORY Patient reports history of kidney stones. FAMILY HISTORY Patient reports his father has a history of kidney stones. MEDICATIONS Patient reports use of Tylenol. REVIEW OF SYSTEMS Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting Genitourinary: Reports dysuria and dark colored urine. Denies hematuria. PHYSICAL EXAM Gastrointestinal - Examination of Abdomen: No masses or tenderness to palpation. No rebound or guarding. No peritoneal signs. Positive CVA tenderness on the right flank. RESULTS Previous CT scan of the abdomen ordered by the patient's PCP is reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter. There is no evidence of hydronephrosis. ASSESSMENT AND PLAN 1. Acute nephrolithiasis. - Medical Reasoning: The patient presents with complaints of right-sided abdominal pain. His previous CT scan was reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter without evidence of hydronephrosis. - Medical Treatment: I have recommended that he push fluids in order to help facilitate urination to help pass the stone. He will be provided with a strainer to allow us to potentially test the stone if he is able to pass it. I have also prescribed oxycodone 5 mg every 6 to 8 hours as needed for pain. He can continue to alternate oxycodone with Tylenol. A basic metabolic panel, urinalysis, and urine culture will also be ordered. INSTRUCTIONS He will follow up in 1 to 2 weeks. If he is still having symptoms at that time, we will discuss further treatment such as lithotripsy or ureteroscopy. He is to contact me if he is having worsening symptoms over the next week.

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

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

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

[doctor] alright so hey it's nice to see you jack i know you've been experiencing some neck pain could you tell me what happened [patient] yeah so i was in a a car accident [doctor] mm-hmm [patient] and i hit in the back and like my my neck went forward and my head went forward really quick and so i've been having some pain ever since [doctor] okay and so with this pain how long ago was the car accident [patient] that was about a week ago [doctor] okay with this pain like on a scale of one to ten how severe is it [patient] i would say it's about a seven [doctor] okay [patient] it's not a constant pain but like whenever i move my head which is like a lot i i feel it [doctor] alright so where exactly is it on the side on the back [patient] it's in the back of my neck [doctor] okay has anything made it better [patient] i mean i've tried some ibuprofen that helped a little bit but not too much [doctor] mm-hmm [patient] just about five out of ten [doctor] mm-hmm alright and did you say whether the pain was getting worse [patient] i mean it's been staying the same it just gets worse when i'm moving my neck [doctor] okay are you able to turn your neck from side to side [patient] mostly but there is there is pain with it [doctor] okay and then do you have headaches [patient] yeah i had i had a couple early on [doctor] uh uh [patient] i have had it lately [doctor] okay and so does the pain move anywhere like your upper back your shoulder [patient] no it just stays on monday [doctor] okay and then any kind of hearing any kind of hearing problems visual disturbances [patient] no [doctor] okay have you do have you ever like played sports before or had like a sports accident before [patient] yeah i played football [doctor] okay [patient] years ago but i i did n't have any issues with my neck though [doctor] okay and then when you got in the car accident did you end up going to the emergency room [patient] no i mean i i know that going to the emergency room that like the english rides like five hundred bucks so i did n't want to do that [doctor] i understand i understand okay was there any like swelling or bruising on your neck [patient] not that i know about no other mag of my neck i really ca n't see that [doctor] yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt [patient] yeah a little bit [doctor] okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders [patient] no that's fine [doctor] okay so when you flex your neck when you're touching your chin to your chest does that hurt [patient] mm-hmm [doctor] alright positive pain with flexion what about when you move it back [patient] yeah that hurts worse [doctor] okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt [patient] yeah a little bit [doctor] okay positive pain with rotation and then can you touch your ear to your shoulders [patient] no [doctor] okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe what you have is something called neck strain for your neck pain i sorry treatments we are gon na go ahead and treat this a bit conservatively your i'm gon na put you on anti-inflammatories motrin six hundred milligrams and you're gon na take that every six to eight hours i also wan na give you a muscle relaxant called flexeril and it's gon na be ten milligrams and you'll take that every twelve hours as needed i'm gon na want you to try your best to to like relax your neck i'm sorry not to strain your neck anymore like to be conservative with how you move about and everything like that i also wan na order an mri just because you said you did n't go to the hospital or anything like that i just wan na make sure that you you're not suffering from like a concussion but this is something that's commonly referred to as like whiplash right your head just like it it just wiped essentially like back and forth to so severely and and that's probably what's causing your pain i think i wan na refer you to either physical rehab or a chiropractor once we get the results of the mri just to make sure that there is n't any impingement of like the nerves or anything like that do you have any questions [patient] i heard the chiropractors will shake they work [doctor] i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like that rehab and physical therapy [patient] okay [doctor] alright any other questions [patient] no [doctor] alright thank you

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.

[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 Cough, nasal congestion, and rhinorrhea. HISTORY OF PRESENT ILLNESS Randy Gutierrez is a 9-month-old male who is being evaluated today for a cough, nasal congestion, and rhinorrhea. He is accompanied by his mother. Symptoms began yesterday around dinnertime with clear nasal drainage, pulling on his ears bilaterally, and rubbing his nose frequently. He does not have a barky cough or a sore throat. His rectal temperature was 100.3 degrees. The patient did consume a 7 ounce bottle this morning, but mostly denied the next offered bottle and declined cereal. He is irritable and having trouble falling asleep, described “like he is fighting it”. The patient has been exposed to an older sister who is sick and a cousin who has a sinus infection. Treatment has included saline nasal spray, Tylenol, baby Vick's, and a humidifier. When the patient aroused this morning, he was warm to the touch. When his sleeper was removed, he was quite sweaty despite the air conditioner being on. The patient's dandruff is also worsening. The only tried treatment is Aveeno shampoo. SOCIAL HISTORY Older sister. CURRENT MEDICATIONS Tylenol PRN. PHYSICAL EXAM Temperature 100.3 degrees. Ears, Eyes, Nose, Throat Nasal congestion, clear mucus, rhinorrhea. Bilateral pulling of ears, no sore throat or hoarseness. Respiratory Positive for cough. ASSESSMENT • Viral infection • Dandruff PLAN Viral infection The patient presents with a viral infection and does not need antibiotics currently. I advised continuation of fluids, rest. Additionally, I suggested trying Zarbee’s for children under 1 years old. If a croup cough develops, the patient will receive a 0.5 teaspoon. I also provided counseling to the mother to avoid giving honey to the patient for his first year of life due to botulism spores. Dandruff The patient is experiencing worsening symptoms of dandruff. I recommended Head and Shoulders shampoo, Selsun Blue, or Nizoral A-D 2 times per week, combined with his usual shampoo. I counseled the mother that she should be careful not to get the shampoo in the patient eyes and to not use the extra strength shampoos. Additionally, he may also use baby oil and a soft brush on the area. INSTRUCTIONS Return in one week for a re-check.

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

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

[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 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] um , hi mrs. anderson . right ? [patient] yeah . yes , doctor . [doctor] what brings you here today ? [patient] hi , doctor . um , i'm having this left shoulder pain lately , uh , and it's paining a lot . [doctor] okay . all right . hey , dragon . i am seeing mrs. anderson , a 44-years-old female , uh , complaining to check the left shoulder pain . um , so how long how has this lasted ? [patient] it's been a week , doctor . yeah . [doctor] a week . [patient] yeah . [doctor] um , did you take any medication yourself ? [patient] no , i did not take any pain medications . actually , i did . i did take a tylenol for two or three days , but then that did n't help at all . so , uh , the reason why it started or when it started to happen is- [doctor] yeah . [patient] . i was actually in gymnastics class . [doctor] yeah , okay . [patient] and , uh , i do n't know . maybe i must have toppled over into some weird position , so it started to pain since then , uh , because of a certain move . [doctor] okay , uh- [patient] i went overboard , i think . yeah . [doctor] all right , lem me , uh , take a quick look . uh , can you move up a little bit ? yeah . [patient] uh , yeah . in fact , that's hurts . [doctor] does that- does it hurt ? [patient] yeah , it does . [doctor] what if you move back a little bit ? [patient] uh , that also hurts , doctor . [doctor] yeah , okay . [patient] any kind of movement on my left shoulder actually hurts . [doctor] okay . all right , um , so let's ... hey , dragon . show me the last x-ray . all right , from the x-ray , it does n't look like there is any , uh , broken bone or fracture . my guess is you probably , um , hurt your joint , uh- [patient] uh- . [doctor] . a little bit . [patient] mm-hmm . [doctor] so i would , uh , suggest you continue using the pain reliever , maybe just like 600 milligram of ibuprofen three times a day and use it for a week . [patient] and for how long ? yes . [doctor] for a week . [patient] a week , okay . [doctor] and then if you ... if it's still painful , you can use , uh , ice or , um , heat pad- [patient] okay . [doctor] . 'cause that might help relieve your pain . [patient] okay . [doctor] um ... [patient] but i wanted you to know that i did have past surgery on my , um , left arm- [doctor] mm-hmm . [patient] . so , um , i hope that should n't matter , right ? [doctor] um , that does n't seem related to your pain . [patient] okay . [doctor] so ... but i would try to rest my , your left arm- [patient] okay . [doctor] . while it's healing . [patient] okay . [doctor] so , um- [patient] can i , uh , carry any heavy weights or- [doctor] no , no . definitely not . [patient] . anything like that ? [doctor] definitely not . [patient] okay . okay . [doctor] yeah , use , um , right hand- [patient] okay . [doctor] . instead- [patient] mm-hmm . [doctor] . for the next , uh , at least just three to four weeks . [patient] mm-hmm . [doctor] uh , come back to see me if the pain , you know , still there after maybe three weeks- [patient] sure . [doctor] . so we can take a further look . [patient] okay . sure . [doctor] but you should be fine- [patient] yeah . [doctor] . after just resting and regular pain reliever . [patient] okay . all right . [doctor] um- [patient] should we take another x-ray when i come back , if the pain does n't improve ? [doctor] um , maybe . let's see how you're doing in the next three weeks . [patient] uh . [doctor] hey , dragon . um , order medications and procedures as discussed . all right . [patient] okay . [doctor] um , i think that's good for today . hope you feel better soon . [patient] okay . thank you , doctor . [doctor] yeah . [patient] hopefully , the pain reliever , uh , ibuprofen actually helps . [doctor] yeah . [patient] yeah , and if i have more pain , can i call you ? can i fix up another appointment earlier than three weeks ? [doctor] um , you can also try advil . [patient] okay . [doctor] yeah , so , um ... [patient] yeah . [doctor] ale- , aleve . i mean , aleve . [patient] i see . okay , thank you , doctor . [doctor] 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] hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on [patient] and i've been in a lot of pain it started about i would say probably about three days ago [doctor] okay [patient] started having pain on my left back [doctor] okay [patient] and since then i continued to have pain it is traveling a little lower it's gotten little low but i definitely have not passed it yet and i'm just in so much pain [doctor] okay so is the pain that you're having is it constant or does it come and go [patient] it's constant [doctor] okay [patient] all the time i ca n't get comfortable [doctor] alright are you able to urinate [patient] i am and this morning i actually started seeing some blood [doctor] okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes [patient] i've had it for probably this might be my third time [doctor] third time alright [patient] yeah i have n't had one in a while but yeah this is my third time [doctor] okay so have you noticed any nausea chills fever [patient] no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous [doctor] okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain [patient] yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working [doctor] okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved [patient] yeah usually usually about about three four days to pass it yeah [doctor] right so this is this is the looks like this is the third day [patient] yeah [doctor] so we are getting close there [patient] okay [doctor] yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff [patient] i was i have n't been great about taking it but i did get the blood pressure cuff [doctor] so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running [patient] like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty [doctor] okay [patient] and then the bottom number has been between seventy and eighty okay that i mean that's not too bad i think when you were first diagnosed you were up there in the [doctor] the one eighties which was really high [patient] right [doctor] so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that [patient] trying my best but doc i really like my french fries [doctor] yeah [patient] like [doctor] we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help [patient] yeah some help could be helpful okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright [doctor] so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday [patient] i have and those those have been pretty good they are like in the low one hundreds [doctor] okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday [patient] i do [doctor] okay [patient] i do take it [doctor] that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain [patient] no chest pain [doctor] no chest pain are you having any belly pain [patient] the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain [doctor] no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt [patient] yes [doctor] okay i'm gon na press here on your back is that painful [patient] yes [doctor] alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound [patient] that sounds good and i i just i just want this pain to go away so thank you [doctor] okay no problem

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

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

CHIEF COMPLAINT New acne evaluation. HISTORY OF PRESENT ILLNESS Kayla Ward is a 15-year-old female who presents for new patient evaluation of acne located on the face. She is accompanied by her mother today. Kayla states her acne started approximately 2 years ago and it is present almost every day. The patient’s mother notes that the most significant acne flares started in the fall when she was playing school sports. It does not tend to flare with her periods. Kayla reports that today is a good day for her acne. She denies any significant acne present on the chest or back. There are no associated symptoms, including no itching, bleeding, or pain. The patient has been washing her face regularly. Her acne regimen includes washing her face in the morning with Persa-Gel and at night e.l.f. SuperClarify Cleanser along with toner and Persa-Gel. This regimen is somewhat helpful. She wears sunscreen in the summer SPF 30. SOCIAL HISTORY Lives with parents and sister. They have a dog, bird, and rabbits in the home. She is in the 7th grade and active in basketball, volleyball, and tap dancing. FAMILY HISTORY No significant family medical history. PHYSICAL EXAM Integumentary Full exam is performed today except for under the underwear and under the bra. There are multiple benign nevi on the trunk and extremities. Scattered skin-colored papules, open and closed comedones, and erythematous papules on the face, primarily on the forehead, with also some on the central cheeks and chin. The chest and back are relatively spared. The remainder of examination is normal. ASSESSMENT • Comedonal acne. • Multiple benign melanocytic nevi of upper and lower extremities and trunk. Kayla Ward is a 15-year-old female seen today for new acne evaluation. Full skin examination revealed mild to moderate comedonal acne with a small inflammatory component and multiple benign melanocytic nevi of upper and lower extremities and trunk. PLAN Comedonal acne. We discussed the diagnosis, etiology, and treatment options. I recommend starting with topical therapy first. The patient was instructed to wash face every morning with a mild cleanser, then use a non-comedogenic moisturizer with sunscreen SPF 30 of higher. In the evening, wash face with same mild cleanser and allow to dry. Apply a thin layer of topical retinoid, Retin-A 0.1% gel, to acne prone areas. Start off using a few nights a week, slowly work up to using every night. If it is very expensive or not covered by insurance, you can try Differin gel over the counter. Your topical retinoid will cause sun sensitivity, so you will need to wear sunscreen when you are outside. It may also cause some dryness or irritation. Multiple benign melanocytic nevi of upper and lower extremities and trunk. Reassurance given moles are normal in appearance and have no concerning characteristics. Will continue to monitor for progression or changes in 6 months. INSTRUCTIONS Follow recommended cleaning regimen. Start Retin-A 0.1% topical gel, apply to acne prone areas, titrate as instructed. Follow up in 6 months.

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

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

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

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

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

[doctor] hey gregory good to see you today so take a look at my notes and i see that you're here you've had a nonhealing foot ulcer so can you tell me how you're doing how long have you had it what's going on with it [patient] sure so i've had it for about two months now and it's recently become red and is draining so i was concerned about how it's healed [doctor] okay and when you when you got it would you have any trauma to your foot or it just just did it pop up all of a sudden [patient] i think i may have gotten it from walking barefoot on the beach [doctor] okay alright and i saw you you did see your pcp before you came in did they put you on antibiotics [patient] they did start me on some medication but i did n't i did n't pick them up from the pharmacy yet [doctor] okay do you know which ones that they prescribed for you [patient] i do n't recall the name exactly [doctor] do n't recall alright [patient] something i had taken it before [doctor] okay so when you what beach did you go to when you you hurt it [patient] i'm sorry [doctor] so i was asking which beach did you did you go to when you hurt your foot [patient] at i was at dewey beach in my ambulance [doctor] dewey beach wow that sounds like fun i wish i could be a mab right now but all or as lucky as i guess as you are to go to dewey beach okay so does it hurt [patient] it sometimes it throbs does n't i do n't have specific pain but sometimes it does feel like there is some throbbing going on and again my my biggest concern is the it started to drain and it looks a little red [doctor] okay [patient] i have n't had that before [doctor] okay and that makes sense alright so as far as your diabetes you know and i think that's probably a a major cause of this not being able to heal how well are how well is that controlled [patient] i take my medication but i do n't check my sugar all the time [doctor] okay do you [patient] i'm not really sure how [doctor] okay do you know what your last a1c is i'm pretty sure you doc talk to you about it [patient] i think they told me it was around ten [doctor] around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look normal you do n't have a fever so let me just take a look at your foot so on your foot exam there is a one by two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint there is some redness some drainage present you have some edema around it there is fluid like you said that's coming out of it i do n't see any necrosis you do n't have any odor and i do n't appreciate any bony exposure so it pretty much is like you said it's it's red it's swollen i think you have an infection in there as well so when i touch it does that hurt [patient] no i i feel like increased pressure but it's not distinct [doctor] okay alright that's good so before you came in we did get an x-ray of your right foot and there is no evidence of osteomyelitis that means that luckily you do n't have a bone infection so that's great i think it's just in your skin so let's talk a little bit about your assessment and plan so you do have that diabetic foot ulcer and what i wan na do is i wan na order an abi ankle brachial index just to determine the blood supply in your foot to see if we can actually heal that ulcer i'm gon na also perform a debridement here just to take off some of that dead tissue and then i'm gon na prescribe you some clindamycin you can do that four hundred milligrams you take that for seven days take that twice a day just to try to get rid of that infection which you currently do have and that will get rid of some of that that redness and and drainage that that's happening right now did your doc did your pcp give you a surgical shoe something that you would wear while this is happening [patient] they did n't they mentioned that you may be able to give it to me [doctor] okay yeah we could definitely get you a a shoe because if you wear your regular shoes that pressure on that foot can really irritate it and take you backwards so i'll get you a shoe where you can wear that for the next month you know we just wan na make sure that it does heal and then i wan na see you back again in two weeks and we can we'll possibly do another debridement at that time we'll just take a look and see how the tissue is doing so how does that sound [patient] that sounds great [doctor] alright do you have any other question [patient] i do if anything happens in between [doctor] please feel free to call the office yeah please feel free to call you call the office we can definitely get you in you know if you are having any other issues and if it's an emergency if you feel like you're getting a fever feeling well please go to the urgent care or the er if you feel getting black or anything like that but otherwise we'll see you back in two weeks [patient] okay sounds great thanks document [doctor] alright great

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

CHIEF COMPLAINT 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] alright so hey it's nice to see you jack i know you've been experiencing some neck pain could you tell me what happened [patient] yeah so i was in a a car accident [doctor] mm-hmm [patient] and i hit in the back and like my my neck went forward and my head went forward really quick and so i've been having some pain ever since [doctor] okay and so with this pain how long ago was the car accident [patient] that was about a week ago [doctor] okay with this pain like on a scale of one to ten how severe is it [patient] i would say it's about a seven [doctor] okay [patient] it's not a constant pain but like whenever i move my head which is like a lot i i feel it [doctor] alright so where exactly is it on the side on the back [patient] it's in the back of my neck [doctor] okay has anything made it better [patient] i mean i've tried some ibuprofen that helped a little bit but not too much [doctor] mm-hmm [patient] just about five out of ten [doctor] mm-hmm alright and did you say whether the pain was getting worse [patient] i mean it's been staying the same it just gets worse when i'm moving my neck [doctor] okay are you able to turn your neck from side to side [patient] mostly but there is there is pain with it [doctor] okay and then do you have headaches [patient] yeah i had i had a couple early on [doctor] uh uh [patient] i have had it lately [doctor] okay and so does the pain move anywhere like your upper back your shoulder [patient] no it just stays on monday [doctor] okay and then any kind of hearing any kind of hearing problems visual disturbances [patient] no [doctor] okay have you do have you ever like played sports before or had like a sports accident before [patient] yeah i played football [doctor] okay [patient] years ago but i i did n't have any issues with my neck though [doctor] okay and then when you got in the car accident did you end up going to the emergency room [patient] no i mean i i know that going to the emergency room that like the english rides like five hundred bucks so i did n't want to do that [doctor] i understand i understand okay was there any like swelling or bruising on your neck [patient] not that i know about no other mag of my neck i really ca n't see that [doctor] yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt [patient] yeah a little bit [doctor] okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders [patient] no that's fine [doctor] okay so when you flex your neck when you're touching your chin to your chest does that hurt [patient] mm-hmm [doctor] alright positive pain with flexion what about when you move it back [patient] yeah that hurts worse [doctor] okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt [patient] yeah a little bit [doctor] okay positive pain with rotation and then can you touch your ear to your shoulders [patient] no [doctor] okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe what you have is something called neck strain for your neck pain i sorry treatments we are gon na go ahead and treat this a bit conservatively your i'm gon na put you on anti-inflammatories motrin six hundred milligrams and you're gon na take that every six to eight hours i also wan na give you a muscle relaxant called flexeril and it's gon na be ten milligrams and you'll take that every twelve hours as needed i'm gon na want you to try your best to to like relax your neck i'm sorry not to strain your neck anymore like to be conservative with how you move about and everything like that i also wan na order an mri just because you said you did n't go to the hospital or anything like that i just wan na make sure that you you're not suffering from like a concussion but this is something that's commonly referred to as like whiplash right your head just like it it just wiped essentially like back and forth to so severely and and that's probably what's causing your pain i think i wan na refer you to either physical rehab or a chiropractor once we get the results of the mri just to make sure that there is n't any impingement of like the nerves or anything like that do you have any questions [patient] i heard the chiropractors will shake they work [doctor] i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like that rehab and physical therapy [patient] okay [doctor] alright any other questions [patient] no [doctor] alright thank you

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] hey lawrence . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ? [patient] uh , i , i've noticed that i've been swelling up a little bit . i think a lot of it has to do with going to some house parties , eating some salty foods . i feel really lethargic . [doctor] okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ? [patient] it's something like walking up a flight of stairs i'll actually feel it . [doctor] okay . all right . now , um , how long has this been going on for ? [patient] probably about 10 days . [doctor] okay . all right . and you said you're noticed some swelling in your legs ? [patient] a little bit . [doctor] okay . do you have problems lying flat in bed ? [patient] um , i'm a little uncomfortable when i wake up in the morning and i feel pretty stiff . and , and , like , it takes me a little while to adjust to walking when i get up . [doctor] okay . all right . do you ever wake up acutely short of breath at night ? [patient] um , it happened once , probably about a week ago , but it has n't happened since . so i have n't been that concerned about it . [doctor] okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump . [patient] mm-hmm . [doctor] um , are your blood sugars okay ? have you noticed a spike in them recently ? [patient] um , i have n't . i've been pretty good about monitoring it so i ... during the working week , i stay on top of that . but on saturdays or sundays we're so busy i forget to monitor it . but i have n't seen anything spike . [doctor] okay . and i remember your affinity for chocolate bars , so ... [patient] guilty as charged . i love chocolate bars . [doctor] okay . all right . so , in terms of your depression , how are you doing with that ? [patient] uh , it's been a crazy year and a half . um , i've tried some natural solutions . in the summer i did stretches outdoors every morning , which was great , but now the weather changed and , uh , you know , i've got ta find some alternatives . i'm not ready to try any medications just yet , so- [doctor] okay . [patient] . i'm open to some suggestions . [doctor] okay . we'll talk about that . [patient] sure . [doctor] and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole . [patient] mm-hmm . [doctor] you were making some lifestyle modifications , cutting back on your red bull and caffeine . [patient] yeah . [doctor] alcohol intake has been ... how's that been ? [patient] tough during the holiday season , but i'm , i'm better . [doctor] okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ? [patient] no . no . absolutely not . [doctor] okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath . [patient] mm-hmm . [doctor] any other symptoms ? chest pain , fever , chills , cough ? [patient] no . [doctor] um , belly pain ? [patient] no . [doctor] okay . let's go ahead . i want to move on to a physical exam . [patient] mm-hmm . [doctor] hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find . [patient] mm-hmm . [doctor] okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion . [patient] mm-hmm . [doctor] but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ? [patient] okay . [doctor] hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good . [patient] mm-hmm . [doctor] so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every day . [patient] mm-hmm . [doctor] if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911- [patient] mm-hmm . [doctor] . and go into the emergency room . you might need some intravenous diuretics . [patient] mm-hmm . [doctor] okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ? [patient] sure . [doctor] no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ? [patient] not at this point . [doctor] okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ? [patient] you got it . [doctor] hey , dragon ? finalize the notes ...

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

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

CHIEF COMPLAINT 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] 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 .

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

[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 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] 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 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] 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 Esophagitis. HISTORY OF PRESENT ILLNESS Betty Hill is a 53 y.o. female who presents to clinic today for a new patient evaluation of suspected esophagitis. The patient was referred from the emergency department where she was seen in early 10/2020 following 4 days of chest pain. The pain has resolved but she kept this appointment to discuss the original 4-day episode. The patient describes her chest pain in early 10/2020 as sharp and localized behind the sternum. She states that it felt like a heart attack and the onset was sudden. The pain was exacerbated by eating and accompanied by dysphagia. The patient is not able to say whether she had heartburn as she has never experienced heartburn before and is unsure what it feels like. When asked about potential triggers, the patient identifies that she was experiencing a lot of stress at that time due to a job transition. She was able to tolerate the chest pain and dysphagia for 4 days but reports that nothing she tried relieved her symptoms. She then presented to the emergency department and underwent labs and EKG. All results came back normal from these tests. She was not prescribed any medications in the emergency department but was given a referral to me for suspected esophagitis. Her chest pain and dysphagia resolved spontaneously approximately 3 days after her emergency department visit and has not recurred. The patient denies unintentional weight loss, weight gain, abdominal pain, constipation, and diarrhea. She states she is trying to lose weight. PAST HISTORY Medical Uterine fibroids. Anemia. Surgical Cholecystectomy. FAMILY HISTORY None reported. REVIEW OF SYSTEMS • Cardiovascular:  Positive for chest pain. • Gastrointestinal:  Positive for difficulty swallowing. • Psychiatric:  Positive for stress. PHYSICAL EXAM Gastrointestinal Mild tenderness to light palpation in the upper abdominal quadrants. RESULTS The patient’s emergency department records from her 10/2020 visit were reviewed, including the normal cardiac workup. ASSESSMENT The patient presents today following a visit to the emergency department in early 10/2020 for 4-days of sharp chest pain, made worse by eating, and dysphagia. Notably, the patient was experiencing higher levels of stress than normal for her at that time due to a job transition. Her cardiac evaluation in the emergency department was normal and she was referred to me for suspected esophagitis. The patient’s pain and associated dysphagia spontaneously resolved 3 days after her emergency department visit and has not recurred. Possible etiologies of her chest pain and dysphagia include GERD, dyspepsia, esophagitis, musculoskeletal etiologies, and anxiety. Based on her history today, I suspect she had an anxiety attack related to her job transition, plus or minus a contribution from musculoskeletal etiologies. Non-cardiac chest pain. Suspected etiology of anxiety with or without underlying musculoskeletal etiology. PLAN • We discussed the role of an EGD in evaluating her prior symptoms. Given her current asymptomatic status, I am comfortable foregoing the EGD for now in lieu of continued monitoring for symptom recurrence. The patient agreed to notify my office if her symptoms return at which time, we could schedule the EGD. The patient is agreeable to this plan. INSTRUCTIONS • Self-monitor for symptom recurrence and notify my office if this occurs. • Follow up as needed.

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

CHIEF COMPLAINT Right 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] patient's name is diana scott . date of birth , 12/8/1920 . the date of service is 7/9/2021 . this is a new patient note . [doctor] good afternoon . how are you today ? [patient] i'm good , thank you . [doctor] good . well , what brings you in to see me today ? [patient] well , my doctor says that i have a heart murmur . [doctor] okay . [patient] so i do n't know how big a heart murmur i have , or really even what it is . [doctor] okay . so how long have you had that for ? do you have any idea , or is that completely new as far as you know ? [patient] yeah , she said it's a new worrisome heart murmur . so of course , i'm worried as well . [doctor] got it . okay . and are you having any symptoms at all ? [patient] i do n't think so . i do n't know what symptoms i should be having . [doctor] okay . well , so you are 100 , so we ca n't really get around that one . so i expect that you probably do n't move quite as fast as maybe you used to ? [patient] no , i definitely do n't . [doctor] okay . and do you notice that you have any chest pain or f- feel shortness of breath ? [patient] no , i do n't have any chest pain . um , my problem is i have severe pains in my legs , and so she had me going for a chest x-ray , and that was just last week . [doctor] okay . [patient] and so i started taking pain pills for my legs . [doctor] okay , got it , for the legs . and do you feel short of breath at all ? [patient] if i walk too fast or too long , or if i tried to drink a whole glass of water without stopping , then yeah , i do get short of breath that way . [doctor] okay . and how far can you walk before you feel short of breath or sort of overly fatigued ? [patient] well , i do have a walker now , so i do n't know . maybe when i walk to the end of the driveway or i walk around the culdesac . [doctor] got it . all right . [patient] so it is n't that bothersome to me at all . um , maybe more if i try to overdo it . [doctor] okay . [patient] then i , um , i get short of breath if i do overdo it though . [doctor] okay , got it . and so how different would you say , um , that the symptoms are now compared to like six months ago or a year ago ? [patient] i would say probably 70 to 80 % from about six months ago . before that i did n't notice anything at all . [doctor] okay . so do you feel like it's mainly the leg pain that seems to limit you ? [patient] my legs have been severe for about a month now . [doctor] okay . and how about , do you feel lightheaded or dizzy at all ? [patient] yeah . so i do take a pill for that when it does get bad . [doctor] okay . [patient] yeah , and i do n't take it every day , only when i do feel dizzy . [doctor] okay . and so how about any passing out at all ? [patient] no . [doctor] okay , good . and how about irregular heartbeats ? do you ever feel like your heart is going too fast or like it skips a beat ? [patient] i do n't notice it at all . [doctor] okay , great . and how about any swelling in the legs at all ? [patient] yeah , my ankles swell . [doctor] okay . and how long has this been going on ? [patient] um , i would say for probably six months . but it goes up and down , and sometimes it's worse than other times . [doctor] okay . and how about any recent weight gain or anything else like that ? [patient] um , i lost a little bit of weight , but i still weigh a 120 pounds , but i normally weigh about 130 pounds . [doctor] mm-hmm . okay . [patient] um , but that's been going down gradually for about a year . [doctor] okay . and then how about any fevers , chills or anything else that's , that's going on that you can think of ? [patient] no . [doctor] good . so mainly it sounds like you came in , um , mostly because of the murmur . is that right ? and sort of just kind of seeing what things look like ? [patient] yeah , that and i feel overly tired because i take all that medication . [doctor] okay . and so fatigue as well . and have you ever had any testing of your heart done ? [patient] i'm not really sure . [doctor] okay . it does look like you've had a decent number of sh- , uh , surgeries here , ? [patient] yeah , you name it . [doctor] all right . well , i wo n't make you repeat them since i do have a good record . um , but just give me just a second and i'm going to enter the ones we need , okay ? all right . got them . and then , are you taking all the medicines that you went through with madison ? [patient] yes . [doctor] okay , good . and looking at your family history , it looks like maybe your brother had a heart attack . is that correct ? [patient] it was actually my son , not my brother . [doctor] okay , i'll make that adjustment . [patient] um , but my brother did have a stroke . but that was because he had gotten sugar diabetes , and my eldest sister did have a heart problem as well . [doctor] okay , i see . [patient] yeah , so heart problems kinda run in the family . [doctor] okay . all right . well , it looks like also that you never smoked . that's excellent . and then no allergies to medicines that you know of , is that correct ? [patient] correct . [doctor] all right . well , let's do a quick exam . [patient] all right . sounds good . [doctor] all right . well , for physical exam , please use the regular template . all right , please just breathe normally . great . and now take a few deep breaths for me . all right . do you feel okay ? are you feeling any dizziness or anything ? [patient] no , i feel fine . [doctor] okay , great . all right . well , that is it for the exam . [patient] okay . [doctor] all right . so what i'm thinking is , let's go ahead and schedule you for an echocardiogram . it's a very common test and it just takes a picture of your heart . and it'll let me see how well your heart is actually working . [patient] okay . [doctor] and i can order that for today . um , do you have time to complete that ? it should n't take too long . [patient] yes , that's fine . i have time . [doctor] okay , great . so we will complete that today , um , to assess your overall cardiac structure and function , as well as , uh , the valve view of where diseased . [patient] okay . [doctor] and some hospital outcomes and what we might suggest to fix that out , i'll go over that . so one possible suspicion i'm having is it's called , um , aortic stenosis , and that just means that one of your main valves of your heart has narrowed a bit and the valve does n't really open , um , quite fully . and this could just reduce or block the blood flow from your heart into the main artery of your body , and that's called the aorta , into the rest of your body . [patient] okay . [doctor] and if this is severe , then we might wan na perform a procedure called the transcatheter aortic valve replacement , or we just call it tavr . and it is a minimally invasive procedure to replace the valve . [patient] well , i would have to think about that . i'm not too sure i'd wan na do that , given my age of all . [doctor] yeah , sure , no problem . and we do n't have to make any decisions today , just , you know , wanted to go over a couple of these things . um , but sometimes we can also perform a surgical aortic valve replacement , or it's called an savr . but really , because of your age and medical history , um , unfortunately , that would n't be a good option for you . [patient] i see . okay . well , i guess we'll see , um , what you see from , from the , um , test . [doctor] yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently . [patient] okay , good . [doctor] and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able to stop your statin . [patient] really ? [doctor] yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin . [patient] okay , that sounds great . thank you . [doctor] you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them . [patient] okay , i will . [doctor] all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ? [patient] not that i can think of . thank you so much . and i think it looks good . [doctor] okay , awesome . all right . well , have a good rest of your day , and we'll see you soon . [doctor] for physical exam , constitutional elderly otherwise no acute distress . cardiovascular normal s1 and s2 is preserved with a normal rate and regular rhythm . there is a 4/6 systolic murmur at the right upper sternal border with , uhm , mild radiation to the carotids . neurologic gait is normal for age . [doctor] for assessment and plan , probably one cardiac murmur . diana has a 4/6 systolic murmur at the upper right sternal border with mild radiation to the carotids . this is most likely representative of aortic stenosis , for symptoms could be due to severe aortic , aortic stenosis . however , her s2 is relatively preserved , which would be more consistent with , consistent with moderate . some of her outside records do note diastolic dysfunction , so it is possible she , she did have an echocardiogram at some point in the past . she does not appear significantly volume overloaded today . [doctor] her next problem is pvcs . her referral mentioned tachycardia . uh , her ekg today shows sinus rhythm with frequent pvcs , as well as an anterior septum infarct pattern . she does not have any significant palpitations and we will check an echocardiogram to assess overa- overall cardiac structure and function . depending on results as well as the severity of her aortic stenosis , we will need to consider an ischemic evaluation , or further , possibly a heart mon- monitor to assess overall burden of the pvcs . at this point , she's asymptomatic , so we will start with the echocardiogram only . [doctor] her next problem , hypolipidemia , is managed by her pcp . due to bilateral leg pain over the last month , considered tavr evaluation following echocardiogram . statin could be indicated . [doctor] and next problem , lightheadedness , dizziness . she is on meclizine for this . it is possible that some of her lightheadedness and dizziness is related to the aorta stenosis , and we will do an echocardiogram as noted above . pvcs on her ekg could be contributing , but she does not feel palpitations . we will consider a monitor , but start with the echocardiogram first as noted above . follow up three to four weeks after her echocardiogram is done to discuss results and next steps . end of dictation .

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

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

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

[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 Annual exam. HISTORY OF PRESENT ILLNESS Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen. The patient states she is doing well. She has been walking, exercising, and doing yoga, which has helped with her arthritis. She denies issues with stiffness, pain, or flare ups over the last year. The patient has continued utilizing methotrexate 2.5 mg once a week and denies issues with that. In terms of her atrial fibrillation, she endorses continued palpitations. The last episode she had was about 1 week ago. She has noticed that when she starts to get stressed they start to flare up again. She has tried meditation and running with her dog for stress relief, however these have not been helpful. The patient had called last month and had an event monitor done. Regarding her GERD, she has continued to utilize Protonix 40 mg a day. The patient has cut out soda, which seemed to help. She has not had a flare up in over 5 months. The patient endorses nasal congestion because of her allergies. She denies chest pain, shortness of breath, nausea, and vomitting. REVIEW OF SYSTEMS • Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies. • Cardiovascular: Denies chest pain or dyspnea. Endorses palpitations. • Respiratory: Denies shortness of breath. • Musculoskeletal: Denies joint pain. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Regular rate and rhythm. Slight 2/6 systolic ejection murmur. • Musculoskeletal: No lower extremity edema. Edema and erythema of the right elbow. Pain to palpation of the right elbow. RESULTS Event monitor: Positive for conversion pause. Autoimmune panel: Normal. Well controlled rheumatoid arthritis. ASSESSMENT AND PLAN Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen. Rheumatoid arthritis. • Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal. • Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today. • Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know. Atrial fibrillation. • Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause. • Specialist Referrals: We will refer her to cardiology for a cardiac ablation. GERD. • Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months. • Medical Treatment: Continue on Protonix 40 mg daily. • Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[doctor] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . [doctor] hello , how are you ? [patient] i'm good , thank you . [doctor] so tell me what brings you in today . [patient] recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic . [doctor] or how have you been feeling in general with this ? [patient] not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me . [doctor] okay . are there any other symptoms ? [patient] i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess . [doctor] sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ? [patient] yeah , i've been anemic since i was 13 years old . [doctor] right . so why do your doctors think you're anemic ? do you have a history of heavy periods ? [patient] well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly . [doctor] yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ? [patient] about five to six years ago . [doctor] and was it relatively a normal exam ? did you have any polyps ? [patient] no . they said they'd see me in 10 years . [doctor] well that's good news . [patient] yeah , i agree . [doctor] um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ? [patient] no . [doctor] all right . do you ever drink alcohol ? [patient] yeah , but only once or twice a year . [doctor] okay . are you taking any supplements such as iron or vitamin b12 ? [patient] i already started taking my iron pills which i have not taken in about a year . [doctor] all right . and what are you taking ? [patient] i'm taking 25 milligram tablets , twice daily . [doctor] okay , and that's the , the ferrous sulfate ? [patient] yeah , that's it . i take one in the morning and one in the evening . [doctor] okay . anything else ? [patient] yeah , i take vitamin b12 , just the over the counter stuff . [doctor] okay , very good . all right , well let's go ahead and take a look and see what's going on . [patient] sounds good . thank you . [doctor] of course . you'll hear me , uh , talk through your exam so that i get all the information documented . [patient] okay . [doctor] all right . so use my general physical exam template . i will start by listening to your heart and lungs . [patient] okay . [doctor] all right . next , i'd like you to lay back so i can examine your abdomen . [patient] okay . [doctor] is there any tenderness where i'm pressing ? [patient] no . [doctor] okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding . [patient] is that why they want me to have another upper endoscopy ? [doctor] actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why . [patient] lovely . [doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . [patient] okay . [doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . [patient] all right . [doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled . [patient] okay . [doctor] um , have you ever had any issue with sedation in the past ? [patient] no , i was just sleepy afterwards . [doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [patient] okay . sounds like a plan . [doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . [patient] okay , that sounds great . [doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you . [patient] thank you . [doctor] you're welcome . have a great day , have a great day ms. cooper . [patient] you too . [doctor] all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .

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 , 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 .

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] 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 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 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 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] 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

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.

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

CHIEF COMPLAINT Right shoulder pain. HISTORY OF PRESENT ILLNESS Bobby Flores is a 56-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of right shoulder pain. The onset of his pain began a few weeks ago, when he was performing different projects in his backyard. He states that he was sore all over the next couple of days. He locates his pain to the lateral aspect of his right shoulder. His pain is aggravated with movement. The patient denies any restriction with his arm. He also reports pain at night when he sleeps on his right side. The patient denies any numbness in his arm or hands. He has been taking Advil and icing his shoulder, which provides some relief. The patient reports a history of right shoulder pain when he was younger while playing baseball. The patient also has complaints of bilateral foot and ankle pain. He attributes this pain to the yard work he has been doing. For treatment, he has iced and elevated them, which provided some relief. REVIEW OF SYSTEMS Musculoskeletal: Positive for right shoulder pain. Neurological: Negative for numbness in hands. VITALS Temperature: 97.8 degrees F. Heart Rate: 62 BPM. Respirations:16. Blood pressure: 116/84 mm Hg. Oxygen saturation: 99 percent on room air. PHYSICAL EXAM CV: >Capillary refill is less than 3 seconds. NEURO: Normal sensation. Neurovascularly intact on the right. Sensation to touch is intact on the right shoulder. MSK: Examination of the right shoulder: Limited active and passive ROM. Tenderness at the greater tuberosity of the humerus. No tenderness at the sternoclavicular or AC joints. Good hand grip. RESULTS 3 views of the right shoulder were taken. These reveal no fracture or dislocation. No abnormalities noted. ASSESSMENT 1. Right shoulder rotator cuff tendinopathy. 2. Bilateral foot pain. 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 did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the right shoulder to evaluate for a possible rotator cuff tear. I have also recommended that the patient attend formal physical therapy for 6 to 8 weeks. He can continue taking Tylenol as needed for pain. If his symptoms do not improve with physical therapy, I will recommend a cortisone injection. In regards to his bilateral feet pain, I have recommended that we treat the patient conservatively. I am recommending the patient soak his feet in an Epsom salt soak as well as elevate as needed.

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

CHIEF COMPLAINT 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] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . [doctor] hello , how are you ? [patient] i'm good , thank you . [doctor] so tell me what brings you in today . [patient] recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic . [doctor] or how have you been feeling in general with this ? [patient] not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me . [doctor] okay . are there any other symptoms ? [patient] i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess . [doctor] sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ? [patient] yeah , i've been anemic since i was 13 years old . [doctor] right . so why do your doctors think you're anemic ? do you have a history of heavy periods ? [patient] well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly . [doctor] yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ? [patient] about five to six years ago . [doctor] and was it relatively a normal exam ? did you have any polyps ? [patient] no . they said they'd see me in 10 years . [doctor] well that's good news . [patient] yeah , i agree . [doctor] um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ? [patient] no . [doctor] all right . do you ever drink alcohol ? [patient] yeah , but only once or twice a year . [doctor] okay . are you taking any supplements such as iron or vitamin b12 ? [patient] i already started taking my iron pills which i have not taken in about a year . [doctor] all right . and what are you taking ? [patient] i'm taking 25 milligram tablets , twice daily . [doctor] okay , and that's the , the ferrous sulfate ? [patient] yeah , that's it . i take one in the morning and one in the evening . [doctor] okay . anything else ? [patient] yeah , i take vitamin b12 , just the over the counter stuff . [doctor] okay , very good . all right , well let's go ahead and take a look and see what's going on . [patient] sounds good . thank you . [doctor] of course . you'll hear me , uh , talk through your exam so that i get all the information documented . [patient] okay . [doctor] all right . so use my general physical exam template . i will start by listening to your heart and lungs . [patient] okay . [doctor] all right . next , i'd like you to lay back so i can examine your abdomen . [patient] okay . [doctor] is there any tenderness where i'm pressing ? [patient] no . [doctor] okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding . [patient] is that why they want me to have another upper endoscopy ? [doctor] actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why . [patient] lovely . [doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . [patient] okay . [doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . [patient] all right . [doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled . [patient] okay . [doctor] um , have you ever had any issue with sedation in the past ? [patient] no , i was just sleepy afterwards . [doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [patient] okay . sounds like a plan . [doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . [patient] okay , that sounds great . [doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you . [patient] thank you . [doctor] you're welcome . have a great day , have a great day ms. cooper . [patient] you too . [doctor] all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .

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

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

[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 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] next is betty hill , uh , date of birth is 2/21/1968 . she has a past medical history of uterine fibroids and anemia . she's a new patient with a referral from the er of esophagitis . um , i reviewed our records from the er , including the normal cardiac workup , and we're about to go in and see her now . good morning . you miss hill ? [patient] good morning . yes . that's me . [doctor] hey , i'm dr. sanders . it's nice to meet you . [patient] nice to meet you too . [doctor] so tell me about what brings you in today ? [patient] well , i really needed to see you three months ... three months ago , but this was your first available appointment . when i called to make the appointment , i was having chest pains , but it stopped after four days , and i have n't had any since then . [doctor] okay . when did these four days of chest pain occur ? [patient] um , early october . [doctor] of 2020 , correct ? [patient] yes . [doctor] okay . can you think of anything that might have caused the chest pain ? did you wake up with it ? [patient] no . it just it randomly . i tolerated it for four days but then had to go to the emergency room because nothing i did relieved it . they did a bunch of testing and did n't find anything . [doctor] okay . can you point to the area of your chest where the pain was located ? [patient] well , it was here in the center of my chest , right behind my breastbone . it felt like i was having a heart attack . the pain was really sharp . [doctor] did they prescribe you any medications in the er ? [patient] no . they ran an ekg and did blood tests , but like i said , everything was normal . [doctor] okay . i see . [patient] they thought it was something to do with the gi system , so that's why they referred me here . [doctor] interesting . uh , do you remember having any heartburn or indigestion at , at the time ? [patient] uh , maybe . i do n't think i've ever had heartburn , so i'm not sure what that feels like . [doctor] was the pain worse with eating or exercise ? [patient] yes . with eating . [doctor] okay . any difficulty swallowing ? [patient] mm-hmm . i did . [doctor] okay . and that's also resolved since the initial episode three months ago ? [patient] yes . thankfully . the chest pain and swallowing problem got better about three days after i went to the er . but i just feel like there's something wrong . [doctor] okay . so how has your weight been . [patient] i've been trying to lose weight . [doctor] that's good . any in- ... issues with abdominal pain ? [patient] uh , no . [doctor] okay . good . and how about your bowel movements ; are they okay ? [patient] they're normal . [doctor] all right . are you aware of any family history of gi problems ? [patient] i do n't think so . [doctor] have had you had any surgeries on your abdomen , or gall bladder , or appendix ? [patient] yes . they took my gall bladder out several years ago . [doctor] okay . if you wan na lay down here on the table for me and lets take a look at you . [patient] okay . [doctor] so when i push on your lower belly , do you have any pain , or does it feel tender ? [patient] no . [doctor] okay . how about up here in your upper abdomen ? [patient] yes . it , it hurts a little . [doctor] okay . and even when i press lightly like this ? [patient] yes . uh , just a little uncomfortable . [doctor] okay . does it hurt more when i press over here on the left or over here on the right ? or is it about the same ? [patient] i'd say it's about the same . [doctor] okay . so we'll say you have some mild tenderness to light palpation in the upper abdominal quadrants , but everything on your exam looks normal and looks good . [patient] okay . good . [doctor] so let's talk about your symptoms real quick . obviously , with the chest discomfort , we worry about heart issues , but i'm reassured that those were ruled out with all the testing they did in the er . um , other potential causes could be anxiety , esophagitis , which is irritation of the esophagus . but typically with these , um ... but typically , these cause the pain that would last for a long time rather than that isolated incident like you had . um , it's also possible that you had intense heartburn for a few days . [patient] well , since you mention anxiety , i was going through a really stressful job transition right around the time this happened . [doctor] okay . that's good to know . so stress from this could be , um ... could be , uh ... could be very well have contributed to your condition . [patient] okay . [doctor] so we could do an , uh , egd or upper endoscopy to take a look at your esophagus and stomach . this would allow us to look for esophagitis . but your symptoms occurred three months ago and you have n't had any additional episodes , so likely if it were esophagitis , it's already healed by the point ... by this point , and we would n't be able to see anything . the other option is just to continue to monitor , uh , for any additional symptoms at which point we could do the egd . uh , with you being asymptomatic for so long right now , i'm comfortable with that option . but what do you think ? [patient] i'd like to hold off on the egd and wait to see if i have more symptoms . [doctor] that sounds good . um , so you can call the office if you have any additional episodes of pain or any other symptoms you're concerned about . if that happens , we'll get you scheduled for an egd to take a look . if not , you can follow up with me ... follow up with me as needed for any other gi complaints . [patient] okay . [doctor] all right ? if you do n't have any questions for me , i'll walk you out to the check-out desk . [patient] no . that's it . thank you . [doctor] you're welcome . right this way . all right . uh , in assessment , please summarize the patient's history briefly , and let's list her possible etiologies such as , uh , gerd , dyspepsia , esophagitis , musculoskeletal etiologies , and anxiety . uh , suspect she had an anxiety attack related to her job transition , plus or minus a contribution from her musculoskeletal etiologies . um , in the plan , include our discussion of the egd versus monderning ... monitoring for symptom . patient elected to self-monitor her symptoms and will call with any reoccurrence or change . thanks .

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

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

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

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

CHIEF COMPLAINT Upper respiratory infection. HISTORY OF PRESENT ILLNESS Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection. The patient reports that he has been doing a bit of work out in the yard in the last week or so. He started to feel really tired and short of breath. The patient denies coughing up anything, but he feels like he will soon be coughing up phlegm. He denies having a fever, but he felt a little warm. He attributed this to exerting himself. He reports that his elbows hurt quite a bit. He notes his knees were pretty tired and he felt some tension around his knees. The patient attributes these symptoms to lifting heavy bags. He has not been wearing a mask as much recently. He believes that he caught his first cold and his symptoms have worsened. He has had both of his COVID vaccinations. He denies any history of seasonal allergies. Regarding his depression, he states it has been a crazy year and a half. He was a little concerned about that, but for the most part, he has been doing well with it. His wife got him into barre classes and this has been relaxing. Regarding his diabetes, he has been monitoring his sugar levels while he is at work, but is not as consistent on Saturdays and Sundays. His diet has been pretty good for the most part, except for some house parties. They have not been elevated since his respiratory symptoms began. The patient has been monitoring his blood pressure at home. He reports that he is very regular with monitoring his blood pressure during the week, though less consistently on weekends. He reports his blood pressure has been under control. He has continued to utilize lisinopril 20 mg, daily. The patient denies nausea, vomiting, diarrhea. REVIEW OF SYSTEMS • Constitutional: Denies fever. • Cardiovascular: Endorses dyspnea on exertion. • Respiratory: Endorses shortness of breath and cough. • Gastrointestinal: Denies nausea or diarrhea. • Musculoskeletal: Endorses bilateral elbow and knee pain. • Psychiatric: Endorses depression. PHYSICAL EXAMINATION • Respiratory: Scattered rhonchi bilaterally, clears with cough. • Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds. • Musculoskeletal: Edema in the bilateral lower extremities. Pain to palpation of the bilateral elbows. RESULTS X-ray of the chest is unremarkable. No airspace disease. No signs of pneumonia. Hemoglobin A1c is elevated at 8. ASSESSMENT AND PLAN Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection. Upper respiratory infection. • Medical Reasoning: I believe he has contracted a viral syndrome. His chest x-ray was unremarkable and he has received both doses of the COVID-19 vaccination. • Additional Testing: We will obtain a COVID-19 test to rule this out. • Medical Treatment: I recommend he use Robitussin for cough, as well as ibuprofen or Tylenol if he develops a fever. Depression. • Medical Reasoning: He has been practicing barre classes and is doing well overall. • Medical Treatment: I offered medication or psychotherapy, but the patient opted to defer at this time. Diabetes type 2. • Medical Reasoning: His blood glucose levels have been well controlled based on home monitoring, but his recent hemoglobin A1c was elevated. • Additional Testing: We will repeat a hemoglobin A1c in 4 months. • Medical Treatment: We will increase his metformin to 1000 mg twice daily. Hypertension. • Medical Reasoning: He has been compliant with lisinopril and his blood pressures have been well controlled based on home monitoring. • Additional Testing: We will order a lipid panel. • Medical Treatment: He will continue on lisinopril 20 mg once daily. This was refilled today. Follow up: I would like to see him back in approximately 4 months. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[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 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] 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 New acne evaluation. HISTORY OF PRESENT ILLNESS Kayla Ward is a 15-year-old female who presents for new patient evaluation of acne located on the face. She is accompanied by her mother today. Kayla states her acne started approximately 2 years ago and it is present almost every day. The patient’s mother notes that the most significant acne flares started in the fall when she was playing school sports. It does not tend to flare with her periods. Kayla reports that today is a good day for her acne. She denies any significant acne present on the chest or back. There are no associated symptoms, including no itching, bleeding, or pain. The patient has been washing her face regularly. Her acne regimen includes washing her face in the morning with Persa-Gel and at night e.l.f. SuperClarify Cleanser along with toner and Persa-Gel. This regimen is somewhat helpful. She wears sunscreen in the summer SPF 30. SOCIAL HISTORY Lives with parents and sister. They have a dog, bird, and rabbits in the home. She is in the 7th grade and active in basketball, volleyball, and tap dancing. FAMILY HISTORY No significant family medical history. PHYSICAL EXAM Integumentary Full exam is performed today except for under the underwear and under the bra. There are multiple benign nevi on the trunk and extremities. Scattered skin-colored papules, open and closed comedones, and erythematous papules on the face, primarily on the forehead, with also some on the central cheeks and chin. The chest and back are relatively spared. The remainder of examination is normal. ASSESSMENT • Comedonal acne. • Multiple benign melanocytic nevi of upper and lower extremities and trunk. Kayla Ward is a 15-year-old female seen today for new acne evaluation. Full skin examination revealed mild to moderate comedonal acne with a small inflammatory component and multiple benign melanocytic nevi of upper and lower extremities and trunk. PLAN Comedonal acne. We discussed the diagnosis, etiology, and treatment options. I recommend starting with topical therapy first. The patient was instructed to wash face every morning with a mild cleanser, then use a non-comedogenic moisturizer with sunscreen SPF 30 of higher. In the evening, wash face with same mild cleanser and allow to dry. Apply a thin layer of topical retinoid, Retin-A 0.1% gel, to acne prone areas. Start off using a few nights a week, slowly work up to using every night. If it is very expensive or not covered by insurance, you can try Differin gel over the counter. Your topical retinoid will cause sun sensitivity, so you will need to wear sunscreen when you are outside. It may also cause some dryness or irritation. Multiple benign melanocytic nevi of upper and lower extremities and trunk. Reassurance given moles are normal in appearance and have no concerning characteristics. Will continue to monitor for progression or changes in 6 months. INSTRUCTIONS Follow recommended cleaning regimen. Start Retin-A 0.1% topical gel, apply to acne prone areas, titrate as instructed. Follow up in 6 months.

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

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

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

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

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

[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 .

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

[doctor] hi russell how are you what's been going on [patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days [doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee [patient] yeah it kinda burns a little bit [doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay [patient] okay [doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you

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

[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 Back pain. HISTORY OF PRESENT ILLNESS Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with back pain. Mr. Walker reports that he was helping his daughter move some heavy equipment and lifted some heavy boxes a little too quickly on Saturday. He thought he heard a pop when he moved and he had to lie down for about an hour before his pain resolved. He has had stiffness ever since. The pain is located in his lower back. He took Tylenol, ibuprofen, and used Icy Hot on the area, but it did not seem to help. The patient endorses some tingling in his toes on his right foot, which resolved Sunday afternoon. He finds it difficult to find a comfortable position to sleep at night, and he tends to lie on his right side, which seems to help a little bit. Regarding his diabetes type 2, Mr. Walker reports that he has not cooked a meal at home in weeks, due to travel. He notes that his diet has not been great, and he thinks he needs to eat clean for a couple of weeks. He monitors his blood pressure at home and it is under control for the most part. Regarding his osteoarthritis, Mr. Walker reports occasional aggravation of his knee when he runs too much or lifts boxes that are too heavy. The patient denies chest pain, nausea, vomiting, fevers, and chills. REVIEW OF SYSTEMS • Constitutional: Denies fevers, chills. • Cardiovascular: Denies chest pain. • Musculoskeletal: Endorses back pain and stiffness. Endorses knee pain with exertion. • Neurological: Endorsed tingling in toes until Sunday, denies tingling today. PHYSICAL EXAMINATION • Cardiovascular: Slight 2/6 systolic ejection murmur. • Musculoskeletal: Pain to palpation of the lumbar spine. Pain with flexion and extension of the back. Negative straight leg raise. VITALS REVIEWED • Blood Pressure: Elevated RESULTS Hemoglobin A1c is elevated at 8. X-ray of the back is unremarkable. Normal bony alignment. No fracture present. ASSESSMENT AND PLAN Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with low back pain. Lumbar strain. • Medical Reasoning: He injured his lower back while moving heavy boxes. His recent x-ray was unremarkable. • Medical Treatment: Initiate meloxicam 15 mg once a day. • Specialist Referrals: Referral to physical therapy. • Patient Education and Counseling: He was encouraged to continue icing the area and avoid strenuous activity. Diabetes type 2. • Medical Reasoning: His recent hemoglobin A1c was elevated at 8. He does admit to some dietary indiscretion lately. • Additional Testing: Repeat hemoglobin A1c in 6 months. • Medical Treatment: Increase metformin to 1000 mg twice a day. Hypertension. • Medical Reasoning: His blood pressures have been slightly elevated based on home monitoring and in clinic today. • Medical Treatment: Increase lisinopril from 10 mg to 20 mg a day. Osteoarthritis. • Medical Reasoning: This is mostly well controlled. • Medical Treatment: Continue to monitor the knee. No further work up is needed at this time. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

[doctor] hi russell how are you what's been going on [patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days [doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee [patient] yeah it kinda burns a little bit [doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay [patient] okay [doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you

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.

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

CHIEF COMPLAINT Esophagitis. HISTORY OF PRESENT ILLNESS Betty Hill is a 53 y.o. female who presents to clinic today for a new patient evaluation of suspected esophagitis. The patient was referred from the emergency department where she was seen in early 10/2020 following 4 days of chest pain. The pain has resolved but she kept this appointment to discuss the original 4-day episode. The patient describes her chest pain in early 10/2020 as sharp and localized behind the sternum. She states that it felt like a heart attack and the onset was sudden. The pain was exacerbated by eating and accompanied by dysphagia. The patient is not able to say whether she had heartburn as she has never experienced heartburn before and is unsure what it feels like. When asked about potential triggers, the patient identifies that she was experiencing a lot of stress at that time due to a job transition. She was able to tolerate the chest pain and dysphagia for 4 days but reports that nothing she tried relieved her symptoms. She then presented to the emergency department and underwent labs and EKG. All results came back normal from these tests. She was not prescribed any medications in the emergency department but was given a referral to me for suspected esophagitis. Her chest pain and dysphagia resolved spontaneously approximately 3 days after her emergency department visit and has not recurred. The patient denies unintentional weight loss, weight gain, abdominal pain, constipation, and diarrhea. She states she is trying to lose weight. PAST HISTORY Medical Uterine fibroids. Anemia. Surgical Cholecystectomy. FAMILY HISTORY None reported. REVIEW OF SYSTEMS • Cardiovascular:  Positive for chest pain. • Gastrointestinal:  Positive for difficulty swallowing. • Psychiatric:  Positive for stress. PHYSICAL EXAM Gastrointestinal Mild tenderness to light palpation in the upper abdominal quadrants. RESULTS The patient’s emergency department records from her 10/2020 visit were reviewed, including the normal cardiac workup. ASSESSMENT The patient presents today following a visit to the emergency department in early 10/2020 for 4-days of sharp chest pain, made worse by eating, and dysphagia. Notably, the patient was experiencing higher levels of stress than normal for her at that time due to a job transition. Her cardiac evaluation in the emergency department was normal and she was referred to me for suspected esophagitis. The patient’s pain and associated dysphagia spontaneously resolved 3 days after her emergency department visit and has not recurred. Possible etiologies of her chest pain and dysphagia include GERD, dyspepsia, esophagitis, musculoskeletal etiologies, and anxiety. Based on her history today, I suspect she had an anxiety attack related to her job transition, plus or minus a contribution from musculoskeletal etiologies. Non-cardiac chest pain. Suspected etiology of anxiety with or without underlying musculoskeletal etiology. PLAN • We discussed the role of an EGD in evaluating her prior symptoms. Given her current asymptomatic status, I am comfortable foregoing the EGD for now in lieu of continued monitoring for symptom recurrence. The patient agreed to notify my office if her symptoms return at which time, we could schedule the EGD. The patient is agreeable to this plan. INSTRUCTIONS • Self-monitor for symptom recurrence and notify my office if this occurs. • Follow up as needed.

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

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

CHIEF COMPLAINT Annual exam. HISTORY OF PRESENT ILLNESS Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen. The patient states she is doing well. She has been walking, exercising, and doing yoga, which has helped with her arthritis. She denies issues with stiffness, pain, or flare ups over the last year. The patient has continued utilizing methotrexate 2.5 mg once a week and denies issues with that. In terms of her atrial fibrillation, she endorses continued palpitations. The last episode she had was about 1 week ago. She has noticed that when she starts to get stressed they start to flare up again. She has tried meditation and running with her dog for stress relief, however these have not been helpful. The patient had called last month and had an event monitor done. Regarding her GERD, she has continued to utilize Protonix 40 mg a day. The patient has cut out soda, which seemed to help. She has not had a flare up in over 5 months. The patient endorses nasal congestion because of her allergies. She denies chest pain, shortness of breath, nausea, and vomitting. REVIEW OF SYSTEMS • Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies. • Cardiovascular: Denies chest pain or dyspnea. Endorses palpitations. • Respiratory: Denies shortness of breath. • Musculoskeletal: Denies joint pain. PHYSICAL EXAMINATION • Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi. • Cardiovascular: Regular rate and rhythm. Slight 2/6 systolic ejection murmur. • Musculoskeletal: No lower extremity edema. Edema and erythema of the right elbow. Pain to palpation of the right elbow. RESULTS Event monitor: Positive for conversion pause. Autoimmune panel: Normal. Well controlled rheumatoid arthritis. ASSESSMENT AND PLAN Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen. Rheumatoid arthritis. • Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal. • Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today. • Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know. Atrial fibrillation. • Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause. • Specialist Referrals: We will refer her to cardiology for a cardiac ablation. GERD. • Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months. • Medical Treatment: Continue on Protonix 40 mg daily. • Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.