[doctor] we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ?
[patient] i'm good . how are you ?
[doctor] i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ?
[patient] okay .
[doctor] all right . so , michelle is a 31-year-old female with a past medical history of type 2 diabetes and hypertension who presents with abnormal lab finding . so , michelle , it came back to me that you had had a positive long ... lyme titer .
[patient] yeah .
[doctor] and so , uh , can you , you , you know , can you tell me a little bit about it ? i know the last time i saw you , you had had an insect bite , and you know , it came back positive for lyme . so how are you feeling ?
[patient] i've been feeling ... i could feel better . um ... i've been feeling tired , um , really lacking a lot of energy , and i have swollen joints in my elbows , just really hurts .
[doctor] okay . all right . and have you had any , any body aches ?
[patient] yeah , i have .
[doctor] okay . all right . um , and i know that you were out hiking in the woods and , and that type of thing a couple of weeks ago , and we thought that that's where you got the bite . so , um , how's your , how's your appetite ? have you been okay ? a little nauseous ?
[patient] yeah , i've been a little nauseous . i have n't been able to eat much . i've been trying just to keep , you know , toast and crackers and that's all about i've been able to stomach , really .
[doctor] okay , and , and i know that you had had that , that , uh , bite there . have you noticed any other rash anywhere else ?
[patient] yeah , i have .
[doctor] okay . all right . sometimes they kind of describe it as looking as like a bull's-eye .
[patient] yes .
[doctor] is that what it looked like ?
[patient] mm-hmm .
[doctor] okay . all right . well , um , have you had any , any high fevers ?
[patient] uh , no , not that i've noticed .
[doctor] all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?
[patient] they've been okay . i've noticed that they sometimes get a little high and a little low . um , but nothing too far out of range .
[doctor] okay . all right . um , and you're still taking the metformin ?
[patient] yes .
[doctor] okay . all right . good . and then in terms of your high blood pressure , are you monitoring the blood pressures at home ?
[patient] yeah , i , i have a ... i bought a cuff last year , and i've been , um , taking it myself at home . those have looked good . i've been staying away from the salty foods .
[doctor] mm-hmm .
[patient] um , so that's been good .
[doctor] okay . and , um , so you're still taking the lisinopril ?
[patient] yes .
[doctor] okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ?
[patient] no , nothing like that .
[doctor] okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam .
[patient] okay .
[doctor] hey , dragon , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ?
[patient] okay .
[doctor] okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ?
[patient] yeah , it does .
[doctor] okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ?
[patient] no , no pain for that .
[doctor] non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ?
[patient] okay .
[doctor] hey , dragon , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ?
[patient] okay .
[doctor] hey , dragon , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ?
[patient] okay .
[doctor] so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ?
[patient] okay .
[doctor] i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ?
[patient] okay .
so for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ?
[patient] okay .
[doctor] hey , dragon , order a hemoglobin a1c . and for your last problem , your high blood pressure . it looks today like everything is fine . i think you're doing a really good job of managing your hypertension , and i'm going to continue you on the lisinopril , 10 milligrams a day , and i'm gon na go ahead and order a lipid panel , and , um , i want you to continue to record your blood , blood pressure regularly , okay ?
[patient] okay .
[doctor] all right . do you need a refill of that ?
[patient] uh , yes , i do .
[doctor] okay . hey , dragon , order lisinopril , 10 milligrams daily . do you have any questions ?
[patient] no , i do n't .
[doctor] okay , so i'm gon na , you know , the nurse is gon na come in , and she's gon na check you out , and then we'll make a follow-up appointment for you , okay ?
[patient] okay .
[doctor] hey , dragon , finalize the note .

Medical orders:
description: hemoglobin a1c
order_type: lab
reason: type 2 diabetes
description: lipid panel
order_type: lab
description: lisinopril 10 milligrams daily
order_type: medication
reason: hypertension
description: doxycycline 100 milligrams twice a day for three weeks
order_type: medication
reason: lyme disease
description: next week follow-up
order_type: followup