[doctor] next patient is nicole miller . date of birth is 09/18/1949 . patient was called for a follow-up with me for chronic congestive heart failure with diastolic dysfunction . bmp's been , uh , 3,000 in march , and is about six- was up to 6,000 in april . she was increasingly dyspneic . we changed her furosemide and torsemide 20 milligrams by mouth daily . uh to note , the patient is not currently on potassium supplement . her lisinopril had- has also been increased up to 10 milligrams daily in march . also did when i saw her last april . she reported being interested in having her right knee replaced this summer at east metro . it was recommended that we work to control her cardiovascular status before surgery .
[doctor] hey , miss miller , how are you today ?
[patient] i'm doing okay , thank you .
[doctor] i asked you to come in today because we want to keep- we want you to have this knee surgery this summer but we want to keep a close eye on you to make sure a week before your surgery you do n't suddenly go into congestive heart failure and it gets postponed .
[patient] yeah , that would not be good .
[doctor] i see you're scheduled on the 24th for surgery .
[patient] yeah , that's right .
[doctor] okay , good . well it looks like you have lost about 3 , 3 and a half pounds since i saw you last in april . some of that might be water weight , but still , this is positive .
[patient] yeah , i noticed that too . i think the oxyglutinine is helping as well . my urgency to use the bathroom is much better .
[doctor] well that's great .
[patient] yeah , i , i'm pleased about it too .
[doctor] you ever get leg or finger cramps or anything like that ?
[patient] yeah , i had leg cramps the other day , but i thought it might , was maybe just because i was cold as i had my ceiling fan on and fell asleep . i had cramps when i woke up in both legs right here . um i drank pickle juice and it went right away .
[doctor] well do n't , do n't get crazy with the pickle juice because all of the salt in it .
[patient] haha , i know , i only drink about 4 ounces or so .
[doctor] okay good .
[patient] um it went away so i did n't drink anymore . i find it works a lot better than trying to put some cream on my leg .
[doctor] sure just , just keep it in moderation .
[patient] okay .
[doctor] and then are you still on an iron supplement ? and are you using the bathroom okay ?
[patient] uh yes , everything is good .
[doctor] good . how is your heart burn doing ? any problems with that ?
[patient] no , it did get bad for a while so i tried to take some prilosec and then stopped that other one .
[doctor] okay .
[patient] um i did that for like , gosh , i think it was two weeks back in january and have n't had any problems since .
[doctor] great .
[patient] um and after i stopped taking that um i went back to the stomach one , so i'm doing good now .
[doctor] okay and you're still due for a colonoscopy , correct ?
[patient] uh yeah , that's right .
[doctor] all right , let's review your blood work real quick . i checked your hemoglobin level because you have had some anemia in the past but that is still doing great .
[patient] good , that's a relief to hear .
[doctor] your potassium is 3.9 so it's holding steady on the torsemide . your creatinine was .7 not .8 so you're doing well with kidney numbers . your bun may be a tiny bit elevated at 23 which is the number we look for for dehydration sometimes the kidneys , but it's not terrible . um so when i look at your numbers as a whole i think you're tolerating the torsemide okay at the current dose . i also sent out to look at the heart failure number- i sent to look at your heart failure number . there is a test called a bmp that i was monitoring and in march it was up to 3,000 and then went up to 6,000 in april before i made the change . i'm still waiting for those results .
[patient] okay .
[doctor] all in all i think you're doing good on paper though .
[patient] what about , um what's it called , a1c ? does that show up ?
[doctor] um i do n't think i ordered it but i could . your last a1c was 5.5 in march .
[patient] all righty .
[doctor] so your blood sugar is a little bit high , it was 169 today but that kind of depends on what you ate and you were n't fasting for the blood check so i might have to repeat that test for pre-op , but i do n't think we need to do it today .
[patient] all righty that sounds good .
[doctor] i checked your magnesium level because sometimes you uh urinate out magnesium with the water pills but it was normal at 1.7 and your blood pressure is also looking good .
[patient] okay great . that all sounds awesome .
[doctor] all right let's take a quick listen .
[doctor] use my general physical exam template .
[doctor] and take a couple of deep breaths for me .
[doctor] your lungs sound pretty good to me so keep doing what you're doing . um uh , like i said , i think you're doing good overall but let's just talk about a few things .
[patient] all righty .
[doctor] so we often like to keep people with heart problems on magnesium and get their levels up to around the 2-ish range . yours is a little bit less than 2 and we want that 2-ish range because it can help stabilize the heart muscle . so i might recommend putting you on magnesium supplement . it's supposed to be twice a day so that's kind of annoying , but i know you're on other medicines twice a day too , so i think you'll do fine .
[patient] yeah , that'll be okay .
[doctor] great . now before surgery we'll have to get you off your clopidogrel for a week beforehand .
[patient] yes , okay , i have everything written down on my phone , and i have a letter taped to the side of my bed to remind me .
[doctor] perfect ! we will give you a reminder as well . we will also need to complete a pre-op check within two weeks of your surgery during the first or second week of june .
[patient] okay , i'll put that down .
[doctor] you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekgs . um we do n't need to any x-rays of your chest because you had one recently , and we do n't need any more blood work because we did that today .
[patient] yeah , i do a lot of ekgs . i'm basically a regular . but i'm happy to do one today , no problem .
[doctor] lastly , once we get your knee surgery , um we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ?
[patient] yeah , i have both .
[doctor] okay so yes , you can get it , your colonoscopy , wherever you'd like .
[patient] okay , well my husband's insurance may be running out . might we be able to get the procedure done sooner ? maybe in the next 30 days ? is that okay ?
[doctor] um i can put it in right now for , uh , for county for the next 30 days , and they might be able to get you in within the next few weeks . it should not take , it should not make you ineligible for the surgery . in other words completing a colonoscopy would not delay your surgery .
[patient] okay , good .
[doctor] so let me see . i've been doing one of two things at every one , and everyone is great so it depends more on timing availability of their or for the colonoscopy . we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical , and they do it at springfield .
[patient] okay , that sounds good .
[doctor] i think either direction they're good technicians of the colon .
[patient] okay , yeah whatever you can get me in , that works great .
[doctor] so i'll call around . now if you get that done and they tell you 10 years then you'll be good to go .
[patient] great , thank you .
[doctor] you're welcome . have a great day . let us know if you need anything else , okay ?
[patient] sounds good .
[doctor] all right , assessment and plan .
[doctor] chronic chf . mixed presentation . had a exacerbation of cf , chf earlier in the spring . we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about 3 , 3 and a half pounds down in weight . breathing is non-labored . going to repeat ekg today but otherwise continue with her current regimen . labs checked and creatinine is appropriate .
[doctor] uh number 2 , pre-op examination . she is , she's having a right knee replacement end of june . also , she would like to have a colonoscopy performed which we'll try to have done at uh bartley regional , rightley regional hospital in the next month , uh , prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer .
[doctor] uh the next one is diabetes . a1c is 5.1 on the last check so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .

Medical orders:
description: magnesium supplement twice a day
order_type: medication
reason: yours is a little bit less than 2
description: now before surgery we'll have to get you off you clopidogrel for a week beforehand
order_type: medication