DIALOGUE

[doctor] hi , stephanie . how are you ?
[patient] i'm doing okay . how are you ?
[doctor] i'm doing okay . um , so i know the nurse talked to you about dax . i'd like to tell dax a little bit about you , okay ?
[patient] okay .
[doctor] so , stephanie is a 49-year-old female with a past medical history significant for congestive heart failure , kidney stones and prior colonoscopy who presents today for an abnormal lab finding . so , stephanie , i called you in today because your hemoglobin is low . um , how have you been feeling ?
[patient] over the past couple of months , i've been really tired and dizzy . lately , i've been really just worn out , even just , you know , walking a mile or going to work , doing things that i've done in the past every day that have been relatively okay , and i have n't gotten tired . and now , i've been getting tired .
[doctor] okay , yeah . i , you know , the nurse told me that you had called with these complaints . and i know that we have ordered some labs on you before the visit . and it did , it c- you know , your , your , your hemoglobin is your red blood cell count . and now , and that came back as a little low on the results , okay ? so , have you noticed any blood in your stools ?
[patient] uh , no , i have n't . i did about three years ago , um , and i did a colonoscopy for that , but nothing since then .
[doctor] okay , yeah . i remember that , okay . and how about , you know , do your stools look dark or tarry or black or anything like that ?
[patient] no , nothing like that .
[doctor] okay . and have you been , um , having any heavy menstrual bleeding or anything like that ?
[patient] no , not that i've noticed .
[doctor] okay , all right . and any , have you passed out at all , or anything like that ? any weight loss ?
[patient] no , no weight loss or passing out . i have felt a bit dizzy , but it has n't l- led to me passing out at all .
[doctor] okay . so , you endorse some dizziness . you endorse some fatigue . have you , but you have n't had any weight loss , loss of appetite , anything like that ?
[patient] no , nothing like that .
[doctor] okay , all right . so , you know , let's talk a little bit about that colonoscopy . i know you had a colonoscopy about three years ago and that showed that you had some mild diverticuli- diverticulosis . um , no issues since then ?
[patient] nope , no issues since then .
[doctor] okay , all right . and then i know that , uh , you know , you have this slightly reduced heart function , you know , your congestive heart failure . how have you been doing watching your salt intake ? i know that that's kind of been a struggle for you .
[patient] um , it's been more of a struggle recently . i've been traveling a lot . i went up to vermont , um , to go , um , explore the mountains . and along the way i stopped at , you know , mcdonald's and got two cheeseburgers . and so , i , i could be doing better . i've noticed some swelling in my , my legs . um , but nothing too extreme that where i thought i should call .
[doctor] okay , all right . and any shortness of breath or problems lying flat at night , anything like that ?
[patient] no , nothing like that .
[doctor] okay , all right . and then in terms of the kidney stones , i know that you had those a couple years ago , as well . any recent flare ups ? have you had any , any back pain , flank pain , anything like that ?
[patient] no , nothing like that .
[doctor] okay . any blood in your urine that you've seen ?
[patient] no .
[doctor] okay , all right . um , okay . well , i know that the nurse did a review of system sheet when you came in . and we've just talked a lot about your , your s- your symptoms , you know , your dizziness , your fatigue and that type of thing . anything else that i might have missed , fever chills , any nasal congestion , sore throat , cough ?
[patient] uh , i've had a little bit of nasal congestion just because with the seasons changing , i , i get seasonal allergies . but everything else has been okay .
[doctor] okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ?
[patient] okay .
[doctor] hey , dragon , show me the vital signs . so , here in the office today , your vital signs look great . your blood pressure is fine . your heart rates r- right where it should be , which is good , okay ? i'm just gon na do a quick exam . and i'll let you know what , what i find , okay ?
[patient] okay .
[doctor] all right . so , your physical , physical examination looks fine . so , on your heart exam , i do hear a three out of six systolic ejection murmur , which we've heard in the past , okay ? and on your lower extremities , i do notice some trace to one plus pitting edema in your ankles , which is probably from the salt intake , okay ?
[patient] mm-hmm .
[doctor] so , we'll talk about that . i wan na just look at some of your results , okay ?
[patient] okay .
[doctor] hey , dragon , show me the echocardiogram . so , i just wanted to go over the results of your last echocardiogram , that was about six months ago . that shows that you do have the low pumping function of , of your heart at about 45 % , which is not terrible . and it does show that you have some moderate mitral regurgitation . so , that's that slight heart murmur i heard in your exam , okay ? hey , dragon , show me the hemoglobin . and here , this is the hemoglobin that i was referring to . it's low at 8.2 , okay ? so , we'll have to talk a little bit about that , all right ?
[doctor] so , let me go over a little bit about my assessment and my plan for you , okay ? so , for you first problem this new anemia , uh , i wan na go ahead and send off some more labs and anemia profile , just to see exactly what type of anemia we're dealing with . i also wan na go and refer you back to the gastroenterologist for another evaluation , okay ? hey , dragon , order referral to gastroenterology . so , they're gon na do , uh , probably do an endoscopy and another colonoscopy on you . um , but again , i wan na send off those labs just to make sure that it's not something else , okay ?
[patient] okay .
[doctor] for your next problem your congestive heart failure , um , i do think you're retaining a little bit of fluid . so , i'm gon na go ahead and start you on some lasix 40 milligrams once a day . i want you to continue you on your toprol 50 milligrams daily . and as well your , as well , as your lisinopril 10 milligrams a day . i really want you to watch your salt intake , okay ? get a scale , weigh yourself every day . and call me if your weight starts to go up , okay ?
[patient] okay .
[doctor] 'cause i might need to give you more diuretic .
[patient] all right .
[doctor] and for your last problem your kidney stones , uh , i think everything seems to be fine right at this time . again , continue to watch your diet and stay hydrated . um , and i know that might be a little difficult with the diuretic , but do your best . uh , and give me a call if you have any question , okay ?
[patient] okay .
[doctor] all right . any questions right now ?
[patient] not that i can think of .
[doctor] okay , great . hey , dragon , finalize the note .

CLINICAL NOTE

CHIEF COMPLAINT

Abnormal labs.

HISTORY OF PRESENT ILLNESS

Ms. Stephanie Diaz is a 49-year-old female with a past medical history significant for congestive heart failure, kidney stones, and prior colonoscopy, who presents today for abnormal labs.

The patient reports she has been really tired and dizzy over the past couple of months. She reports these symptoms while walking a mile, going to work, and performing daily tasks. She denies any blood in her stools recently but notes she had blood in her stool about 3 years ago and had a colonoscopy for that. She denies any black, tarry stools, heavy menstrual bleeding, unintentional weight loss, or syncope.

Ms. Diaz had a colonoscopy about 3 years ago due to blood in her stool. This showed mild diverticulitis. She denies issues since that time.

Regarding her congestive heart failure, she states she is not doing well with her salt intake. This has been more of a struggle recently as she has been traveling a lot. She has noticed some swelling in her legs but nothing too extreme.

The patient denies recent issues with kidney stones. She denies low back pain, flank pain, or blood in her urine.

Ms. Diaz notes she has had some nasal congestion but attributes this to the season changing. She gets seasonal allergies but everything else has been okay. The patient denies fever, chills, sore throat, or cough.

REVIEW OF SYSTEMS

 Constitutional: Denies fevers, chills, or weight loss. Endorses fatigue.
 Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies.
 Cardiovascular: Denies dyspnea.
 Respiratory: Denies cough, shortness of breath.
 Gastrointestinal: Denies hematochezia, melena.
 Musculoskeletal: Endorses bilateral leg swelling.
 Neurological: Endorses dizziness.

PHYSICAL EXAMINATION

 Cardiovascular: Grade 3/6 systolic ejection murmur.
 Musculoskeletal: Trace to 1+ edema in the bilateral ankles.

RESULTS

Echocardiogram demonstrates decreased ejection fraction of 45%. Moderate mitral regurgitation.

Hemoglobin is 8.2.

ASSESSMENT AND PLAN

Ms. Stephanie Diaz is a 49-year-old female with a past medical history significant for congestive heart failure, kidney stones, and prior colonoscopy, who presents today for abnormal labs.

Anemia.
 Medical Reasoning: This is a new issue. Her recent hemoglobin level was low at 8.2, but she denies any signs of gastrointestinal bleeding or urinary tract bleeding, as well as any abnormal menstrual bleeding. Her colonoscopy from 3 years ago demonstrated mild diverticulosis.
 Additional Testing: We will order an anemia profile for further evaluation.
 Specialist Referrals: We will refer her back to gastroenterology for repeat evaluation with possible endoscopy and colonoscopy.

Congestive heart failure.
 Medical Reasoning: She has noticed some lower extremity edema. Her echocardiogram from 6 months ago demonstrated a reduced ejection fraction of 45%, as well as moderate mitral regurgitation.
 Medical Treatment: We will initiate Lasix 40 mg once daily, and continue with Toprol 50 mg daily and lisinopril 10 mg daily.
 Patient Education and Counseling: She should continue to limit her sodium intake. I advised her to monitor her daily weights and notify me if these start to increase.

Kidney stones.
 Medical Reasoning: She as asymptomatic denies any recent flare ups.
 Patient Education and Counseling: I encouraged her to continue with dietary modifications and proper hydration. She will contact me with any questions or concerns.

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