[doctor] . next patient is michelle king . date of birth : 05/07/1982 . please use toc template . she was admitted to district regional hospital on 06/29/2021 , and was discharged on 07/02/2021 . the patient is a 39-year-old female with history of quadriplegia due to , uh , prior spinal cord injury . she was experiencing increasing concerns for spasms and lightheadedness , significant constipation , and reported diaphoresis . she was evaluated in the emergency department where she was , uh , febrile and had significantly elevated white blood cell count of 23,000 . there were concerns for ongoing urinary tract infection , but she was treated with iv antibiotic therapy . she had labile blood pressure , headache , and vomiting . in the end , she slowly improved . she does have a supra-pubic catheter . cultures were obtained and reviewed . she was eventually discharged after clinical improvement of her symptoms . she presents today to follow up regarding these concerns . hi , michelle . how are you doing ?
[patient] not too bad . and yourself ?
[doctor] i'm good , thanks . so , it looks like you had an infection , right ?
[patient] yeah . but you know , i really do n't think it was a uti .
[doctor] okay .
[patient] i told them when i went to the er ... is that your phone ?
[doctor] it is , yeah . it listens to you and me and it does all of my documentation . it's pretty good stuff . um , tell me what's going on .
[patient] it is , in my humble opinion , that i was just constipated and that was what was causing my blood pressure to be so high . and i hardly pooped when i was there . then when i got home i had a massive poop and i felt much better . i told them that when i was admitted , and they did x-rays and everything , but they said , " no , " as they did n't think that was n't ... that was it . but you know , i felt so much better when i got home and finally pooped .
[doctor] okay . um , and the white cell count was the only thing that i think they were kind of concerned about because it was a little high .
[patient] so i wondered if automatic dysreflexia can affect the white count ?
[doctor] typically , it does n't .
[patient] okay .
[doctor] but , i mean , when i looked at the urine cultures that they checked , the cultures are not very impressive .
[patient] yeah , that's what they said .
[doctor] and when i go back and look , sometimes your white count is just elevated a little bit , and last year it was normal , so ...
[patient] hm .
[doctor] but in saying that , you know , inflammation can do that . so , yeah , you could be backed up and inflamed .
[patient] yeah .
[doctor] uh , they did n't do a cat scan , they just did an x-ray . but you feel like you're back to your normal self now ?
[patient] yeah . i mean , i went in because i knew my blood pressure was out of control .
[doctor] mm-hmm .
[patient] it was giving me a headache and making me throw up . and i know , at that point , i'm at the loss of what i can do at home .
[doctor] yeah , it was good that you went in .
[patient] so i went in and they made me feel better , and then i went home , as you know .
[doctor] well , maybe that's all it was .
[patient] yeah .
[doctor] so you're doing good otherwise ?
[patient] yes , i am .
[doctor] good . let me take a quick listen to you .
[patient] okay .
[doctor] all right . go ahead and take a few deep breaths . and breathe normally . now take several deep breaths . and two more . okay , good . you can relax . any pain or discomfort anywhere ?
[patient] nope .
[doctor] great . so here are my thoughts .
[patient] okay .
[doctor] you may recall it was extremely hot during that period leading up to you going to the hospital . i do n't know if you were inside for the most part ?
[patient] yeah , it was pretty hot , was n't it ? and i go out a bit , but i do tend to stay in more when it's hot .
[doctor] okay . well , if you do get dehydrated even just a little bit it can lead to further , um , or worsening constipation issues .
[patient] mm-hmm .
[doctor] i've had a lot of patients over the last couple of weeks coming in with just weird stuff , and i blame that a little bit on how hot and humid it was the last two weeks of june . so what i would do is wait a couple of weeks and then , if you could , come back in and we could do some , uh , complete blood work , uh , including your white blood cells and a full panel of cholesterol , since it's been a while .
[patient] okay .
[doctor] and it should normalize , but it's too soon to do it now . um , but maybe if i put some labs in you could come in in two to three weeks ?
[patient] sure , i can do that .
[doctor] great . so that appointment will let us kill a bird ... two birds with one stone since you're due to get blood work anyways for cholesterol .
[patient] okay .
[doctor] and then , i just wanted to make sure that the white count is okay , because if it remains elevated then that means there's something else going on with your bowels .
[patient] mm-hmm .
[doctor] i do n't think that's what we'll find , but we'll see .
[patient] i mean , i knew going in that i had n't had a regular bowel movement in a while , even though i drink the miralax every day .
[doctor] yeah .
[patient] when i do n't go , i double up on that .
[doctor] have i ever given you lactulose ? it would be a medicine you use in , um , conjunction with miralax . sort of a rescue type thing .
[patient] is that the stuff that comes in a bottle ?
[doctor] yes .
[patient] then , yes . i have it . it takes about two days to work and then it's a brutal two days .
[doctor] got it . yeah , it can be a little rough , but it works .
[patient] yeah .
[doctor] all right . so we have our plan . any questions ?
[patient] yeah , well , i would like to talk to you about covid , if we can .
[doctor] sure . so where are you at when it comes to the vaccine ?
[patient] i am unvaccinated .
[doctor] so what are your concerns about the vaccine ?
[patient] well , we do n't know the side effects .
[doctor] correct , we do n't .
[patient] it's too soon to tell the side effects , and i'm hearing more and more reports of people getting what's now termed as " vaccine injury " .
[doctor] right .
[patient] which i had never heard of before . i do n't know if it is a new term or not , but my take on the whole thing is that i'm young and healthy enough to beat it , even if my respiratory is limited . i also take a lot of vitamin c.
[doctor] okay .
[patient] i also take multivitamins and i'm closely monitored . so i guess i do n't feel as though i really the vaccine .
[doctor] well , my thoughts are that you actually should be vaccinated . i think you are high risk . if you get covid it's not going to be good for you .
[patient] okay .
[doctor] and i think it's safe . i mean , i understand and hear you . all of these stories out there about this , uh , regarding the vaccine . but i've seen all the bad things that could happen from covid . people have died in my practice , and i do n't disagree that if you got covid you'd probably be okay .
[patient] yeah .
[doctor] but i would consider you as someone that would make me a little bit concerned . i have had healthy people die from covid .
[patient] mm-hmm .
[doctor] i've had some people get really , really sick from it . so personally , i believe that this vaccine is completely safe . i really think that .
[patient] all of them ?
[doctor] yeah , i do , i do . i think there are side effects from all vaccines , so you have to go back and think about it . do you get flu shot every year ?
[patient] no , i do n't .
[doctor] right , well , it's hard for me to convince you because you're making a consistent viewpoint .
[patient] well , i am open-minded to this .
[doctor] mm-hmm . to me , it's , you know , a lot of the stuff out there is fear and most of us health providers have gotten the vaccine . we've seen what the virus can do . i also have gotten all of my kids vaccinated .
[patient] okay .
[doctor] so i'm not concerned about the side effects of this . i do n't think it does anything . um , and we have vaccinated 50 % of the country .
[patient] mm-hmm .
[doctor] the er is full of these vaccines .
[patient] i understand .
[doctor] so there are definitely potential side effects to the vaccine . i mean , there's guillain-barre , and all these things that could happen from the vaccine , but they're just very rare . my thing for you is i'm not convinced that there's alternative stuff or even the treatment we have , like the monoclonal antibodies , that will give help , but it's just my opinion .
[patient] well , that's what i'm here for .
[doctor] yeah . right now the numbers are low . even with the delta variant , when it starts mutating , it's actually good because it becomes more contagious , but less deadly .
[patient] okay .
[doctor] so that's what's gon na happen with covid . that's what's mo- most of the science supports and this is how most pandemics end , is that the virus starts losing its potency .
[patient] sure .
[doctor] but think about it , and if you have any more questions you can certainly let me know , okay ?
[patient] will do .
[doctor] all right . anything else we can discuss today ?
[patient] nope . i think i'm all set . thank you .
[doctor] you're welcome . so we'll see you in two to three weeks . have a good rest of your day .
[patient] thanks , you too .
[doctor] next line heading will be " acute to chronic constipation " . she believes her hospitalization was more likely due to her dysreflexia , from her quadriplegia that typically occurs . she did have a lot of vital signs changes , including blood pressure fluctuations . the patient feels like she has a good bowel regimen , including taking the miralax regularly as a primary treatment for constipation issues as well as lactulose for severe constipation . she feels like this was less likely a true urinary tract infection and was just related to her constipation . however , we did have a good discussion regarding her leukocytosis .
[doctor] i would recommend just in the next three or four weeks to come back in for some updated fasting labs , and we'll repeat the cbc just to make sure her white blood cells tend downward . uh , next line and heading will be " quadriplegia " . um , next line and heading will be " covid vaccine status " . again , she's hesitant . we had a good discussion , and i recommended that the only true preventative mechanism for covid is the vaccine . i do not believe that supplements are necessarily going to help stave this off . i would be concerned if she does n't get the vaccine and i would consider her at high risk based on her quadriplegia status . she does not want to get covid . however , she needs to make these decisions . she is somewhat homeopathic .

Medical orders:
description: blood white blood cells two to three weeks
order_type: lab
reason: significantly elevated white blood cell count of 23,000
description: blood panel of cholesterol two to three weeks
order_type: lab