[doctor] hi joyce , how are you ?
[patient] i'm good . how are you ?
[doctor] i'm doing well . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you when we get started , okay ?
[patient] okay .
[doctor] all right . so , joyce is a 50 year old female with a past medical history significant for copd , congestive heart failure who presents for follow-up to an abnormal lab finding . so , joyce , i , i got the results of your lab , uh , your labs . your hemoglobin was low . uh , so , i asked them to schedule a follow-up appointment with me . so , how are you feeling ?
[patient] i've been feeling really tired lately . over the past couple of months , i've noticed that my energy has really gone down . i used to be really active , um , just trying to be as healthy as i can be , running, climbing . um , i at least try to do an hour or two a day . and over the past month , it's gone slowly downhill . i've just been so tired and exhausted and i have n't been able to really keep up with the way i , i was g- was going with my exercise .
[doctor] okay . all right . um , now , have you had ... have you noticed any blood in your stools at all ?
[patient] uh , no , not really . not , not at this time .
[doctor] okay . and are your stools , like , dark or charry or black looking ?
[patient] no . not that i've noticed .
[doctor] okay . and are you spotting a lot with your periods ?
[patient] no , i'm not .
[doctor] okay . all right . um , and do you have any other ... i know that you are endorsing this fatigue and you feel kind of dizzy and that type of thing . do you have any other symptoms like chest pain , shortness of breath , fever , chills , body aches , anything ?
[patient] no , nothing like that .
[doctor] okay . any weight loss ?
[patient] um , i've noticed a little bit , but that's because i think i've been doing really well with my exercise . um , but nothing too significant .
[doctor] okay . all right . well , let me ask you a little bit about how's the , the copd doing . i , i know that , you know , you've stopped smoking several years ago , but , you know , you still have that em- those emphysema changes on your chest x-ray . so , how are you doing with that ? how's your breathing ?
[patient] it's been okay . um , i have n't been smoking . i ... after i quit , i quit cold turkey and i have n't gone back since . so , that's been doing well . i think , uh , during the changes of season , it gets a little bit harder for me to breathe , but i think that's just because of my allergies .
[doctor] okay . all right . and then from a congestive heart failure standpoint , are you watching your diet , you're watching your salt intake ?
[patient] yeah . i've been doing really well with that . i've been staying away from the french fries , and all the other salty foods that i love to eat , uh , and everything looks great .
[doctor] um , so , french fries are one of my favorite foods , that and fried chicken , so-

[doctor] i give you a lot of credit for staying away from french fries .
[patient] thank you .
[doctor] um , okay . so , you ... so , no swelling in your legs or any- anything like that .
[patient] no , not that i've noticed .
[doctor] okay . and you feel like you have a good support system ?
[patient] yeah . my boyfriend is , is great and i have , um , my brother right down the road .
[doctor] okay . all right . good . i'm glad to hear that . uh , so , let's go ahead . i wan na just do a quick physical exam , okay ?
[patient] okay .
[doctor] hey , dragon , show me the vital signs . all right . well , your vital signs here in the office look good , so , i'm , i'm really happy to see that with the abnormal hemoglobin that we saw . um , i'm gon na just listen to your heart and lungs and press on your belly a little bit and i'll let you know if i find anything , okay ?
[patient] okay .
[doctor] all right . okay . all right . so , on physical exam , you know , i , i do n't appreciate anything cervical lymphadenopathy . your heart sounds really good , but i do hear a , a slight two out of six systolic heart , uh , murmur , um , systolic ejection murmur on your heart exam . your lungs sound clear . your abdomen ... you know , you did have a little tenderness to palpation in your right lower quadrant on your abdominal exam , uh , but i do n't appreciate any lower extremity edema . so , all that means it that we , you know , we hear that heart murmur , which we heard in the past , um , and your belly had some tenderness , so we'll have to talk about that a little bit , uh , going forward , okay ?
[patient] okay .
[doctor] let's look at some of your results , okay ?
[patient] mm-hmm .
[doctor] hey , dragon , show me the hemoglobin . so , here , looking at this , you know , your hemoglobin level is 8.2. somebody like you should have a hemoglobin o- of about 13 , 14 , okay ?
[patient] okay .
[doctor] so , we need to investigate why it's low . hey , dragon , show me the anemia labs . okay . so , looking here at your labs , uh , everything looks good from , from this standpoint . i think some of your anemia labs are still pending at this time that's part of the workup .
[patient] mm-hmm .
[doctor] so , let's go over a little bit about the assessment and plan for you . so , you know , your main problem , this abnormal lab , this low hemoglobin that we found , so , you're anemic and we nee- ... you know , i'm waiting for those anemia labs to come back to find out exactly , you know , what type of anemia you have . i'd like to go ahead and schedule you for an endoscopy a- and a colonoscopy just to make sure that you're not bleeding from your , inside your belly , okay ? um , and i'm ... i'll be in touch when those labs come back to see what further workup we need to do , okay ?
[patient] mm-hmm .
[doctor] for your next problem , the copd , i think you're doing great . you know , i , i do n't think that you , uh , need any further referrals at this time for that . i would just continue staying away from smoking . it does n't sound to be like you need any inhalers at this time . uh , for your third problem , your congestive heart failure , you know , i wan na continue you on the toprol , continue you on the lisinopril and we'll continue you on your current diuretic dosing of 20 , lasix 20 milligrams a day .
[doctor] i'm gon na go ahead and order that referral to g- to gastroenterology . they're the ones who will do the endoscopy and the colonoscopy , okay ?
[patient] okay .
[doctor] hey , dragon , order the referral to gastroenterology . so , i'll be in touch . i'm gon na stay in close contact with you over the next week or so and , uh , we'll get this all sorted out , okay ?
[patient] okay .
[doctor] all right . take care , joyce .
[patient] thank you .
[doctor] hey , dragon , finalize the note .

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