[doctor] hi , james , how are you ?
[patient] hi , 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] james is a 57 year old male with a past medical history significant for coronary artery disease and lupus , who presents today with joint pain . so james , what's what's going on ?
[patient] yeah . i've been putting a , a few more miles on the bike each day and , uh , my knees have been killing me , just more so in the last three or four days or so .
[doctor] okay . is it one knee versus the other , or both ?
[patient] both equally .
[doctor] okay . and , um , does it hurt more in the morning when you wake up , or does it hurt more when you're walking around and that type of thing ?
[patient] usually when i get up in the morning , they're pretty stiff and sore , and then by the end of the day , i start to feel that same sensation . kind of pretty much , like , uh , probably around dinner time or so .
[doctor] okay . and any other , any other joints bothering you , your elbows , wrists , shoulders , anything like that ?
[patient] no , it's just the knees .
[doctor] just the knees . and have you noticed any swelling of your knees , or any redness of your knees ?
[patient] uh , they look a little inflamed in the morning , and then in the afternoon , same but not as bad , not as noticeable .
[doctor] okay . and do you have any other symptoms with this ? do you have any other associated fatigue or fever or anything like that ?
[patient] no , no .
[doctor] okay . and no injury ?
[patient] no , no . just , uh , repetitive motion , riding the bike the everyday , it , it's part of my workout , i just probably , uh , probably doubled the miles .
[doctor] okay , all right . well , tell me a little bit about . uh , you know , it's been a while since i've seen you . you know , in terms of your heart disease , and i know you got the stent placed last year .
[patient] mm-hmm .
[doctor] um , i know they took you off the plavix , are you still taking your aspirin every day ?
[patient] i am .
[doctor] okay . and how are you doing with your crestor ? any problems with that ?
[patient] no , none whatsoever .
[doctor] okay . and any chest pain or shortness of breath ?
[patient] no .
[doctor] no ? okay .
[doctor] okay . all right , and in terms of your lupus , we have , you know , this is something that was kinda back in the , in the background for you , and we have n't had to do a whole lot . you know , your kidney function's been really good . um , any , any issues as far as you know ?
[patient] no , nothing , not at least in the last year or so .
[doctor] okay . i think we , we might have to look into it a little bit further with this knee pain that you're having .
[patient] okay .
[doctor] but i wan na go ahead and , um ... you know , i know that the nurse did a review of system sheet and we just covered a lot here .
[patient] mm-hmm .
[doctor] any other symptoms , abdominal pain , nausea , vomiting ?
[patient] no , no .
[doctor] no , just the knee pain ?
[patient] mm-hmm .
[doctor] okay . all right . well , let's go ahead and do a quick physical exam .
[patient] okay .
[doctor] hey , dragon , show me the vital signs . so your vital signs here in the office look really good .
[patient] mm-hmm .
[doctor] there's no fever , your blood pressure and your heart rate look great , so that's , that's awesome .
[patient] mm-hmm .
[doctor] um , i'm just gon na check out your heart and your lungs .
[patient] sure .
[doctor] and your knees , and i'll let you know what i find , okay ?
[patient] okay .
[doctor] all right . so on physical examination of your heart , you know , i do hear that's , like , two out of six systolic ejection murmur , but we've heard that in the past . your lungs sound nice and clear . and on your knee exam , i do appreciate , you know , some bilateral , uh , edema and some slight erythema , there is a slight effusion present on the right knee . does that hurt ?
[patient] little bit .
[doctor] all right , so pain to palpation of the right knee . um , and decreased range of motion of the knees bilaterally . so i just wan na look at some of your results , okay ?
[patient] mm-hmm .
[doctor] hey , dragon . show me the right knee x-ray . so this is an x-ray of your right knee and in reviewing the results of that , everything looks fine , there's no boney abnormality , there's no fracture , which is not surprising , based on the history , okay ?
[patient] mm-hmm .
[doctor] hey , dragon . show me the ekg . and this is your most recent ekg which we did before you came in , and that all looks really good . so , um , so no concerns from a heart standpoint . so let's talk a little bit about , you know , my assessment and my plan for you .
[patient] mm-hmm .
[doctor] so for your first problem , your , your knee pain , you know , i'm concerned that it might be from , you know , a flareup of your lupus , so i wan na go ahead and order and autoimmune panel to kinda see where we stand , okay ?
[patient] sure .
[doctor] hey , dragon . order an autoimmune panel . for your next problem , the coronary artery disease , i think you're doing really well , your ekg looks good , your vital signs look good .
[patient] mm-hmm .
[doctor] i'm gon na go ahead and order a lipid panel and another echocardiogram , okay ?
[patient] okay .
[doctor] hey , dragon . order an echocardiogram .
[doctor] do you have any questions ?
[patient] no questions .
[doctor] all right , well , the nurse will be in soon and she'll get you checked out , okay ?
[patient] you got it .
[doctor] hey , dragon . finalize the note .

Medical orders:
description: autoimmune panel
order_type: lab
reason: i'm concerned that it might be from , you know , a flareup of your lupus
description: lipid panel
order_type: lab
reason: coronary artery disease
description: heart echocardiogram
order_type: imaging
reason: coronary artery disease