DIALOGUE

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

CLINICAL NOTE

CHIEF COMPLAINT

Smoking cessation.

MEDICAL HISTORY

Patient reports a history of type 2 diabetes, gout, and a 2/6 Systolic ejection murmur.

SOCIAL HISTORY

Patient reports he is a smoker.

MEDICATIONS

Patient reports taking allopurinol.

VITALS

Oxygen Saturation: 98% on room air.
Blood Pressure: 128/88 mmHg.
Heart Rate: 68 beats per minute.
Respiratory Rate: 16 breaths per minute.

PHYSICAL EXAM

Neck
- General Examination: Neck is supple without lymphadenopathy. No carotid bruits.

Respiratory
- Auscultation of Lungs: Clear bilaterally. No expiratory wheezes, rales, or rhonchi.

Cardiovascular
- Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur.

Hematology/Lymphatic/Immunology
- Palpation: No enlarged lymph nodes.

ASSESSMENT AND PLAN

1. Nicotine dependence.
- Medical Reasoning: The patient has a long history of smoking cigarettes. He is currently smoking 1.5 packs per day. He is highly motivated to cease smoking as he is preparing to become a father.
- Patient Education and Counseling: I applaud the patient on making this first step to stop smoking. I reassured him that with absolute 100% certainty that I will be with him every step of the way. I explained to the patient that stress can often be a trigger for smoking. He received handouts today for common smoking triggers. I advised him to be watchful and monitor his stress level, not only regarding work, but also his impending fatherhood. The patient and I discussed coping mechanisms for when he encounters stressful situations. I encouraged him to maintain his gym routine, engage in meditation, and try adding in yoga to help further reduce his stress levels. We discussed additional cessation aids.
- Medical Treatment: The patient has chosen his birthday, as a quit date. On that day, I am going to start him with a 21 mg nicotine patch, and the goal will be to decrease that over time. We will work together to decrease the dosage of the nicotine patch, so there are not necessarily any hard dates in mind. I recommend he change the patch location each day as that will help reduce or avoid any skin irritation that can occur if he re-uses the same location repeatedly.

2. Type 2 diabetes.
- Medical Reasoning: Stable.
- Patient Education and Counseling: We discussed that continuing to follow a healthy diet and perform regular exercise will help to maintain his blood glucose levels.
- Medical Treatment: We will continue to monitor his type 2 diabetes. Hemoglobin A1c is ordered to be completed by his next visit in 2 weeks.

3. History of gout.
- Medical Reasoning: Stable with medication.
- Patient Education and Counseling: I advised him to continue to watch for foods that will exacerbate his uric acid levels.
- Medical Treatment: He will continue his allopurinol.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

INSTRUCTIONS

I would like to see him again in 2 weeks to discuss how things are going and to reevaluate the nicotine patch dosage.