[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 .

Medical orders:
description: anemia profile
order_type: lab
reason: anemia
description: lasix 40 milligrams once a day
order_type: medication
reason: congestive heart failure