[doctor] next patient is christine hernandez , uh , date of birth is january 13th , 1982 .
[doctor] hey , miss christine , how are you doing today ?
[patient] i'm good , thanks . how are you ?
[doctor] i'm pretty good . so it looks like you've completed the covid vaccine , that's great .
[patient] yes , i did .
[doctor] anything new since your last visit ?
[patient] no , i did all the tests that you had recommended me to take . i have n't been able to take the thyroid medicine , the one that you prescribed , as i'm still taking my old one . um , the price was a little high on the new one .
[doctor] okay , so did ... did you try the coupon that i gave you ?
[patient] i did not try the coupon , uh , there was a charge of $ 75 .
[doctor] okay , well , next time that ... that coupon should help , and it should only be about $ 3 .
[patient] okay , um ... i do n't have it , do you happen to have another one you can give me ?
[doctor] yep , right here .
[patient] wonderful , thank you so much , and ... and then the gel , they are charging me $ 100 for it . so , i do n't know if this is because it's a ... it's wal-mart , or if i should try somewhere else , or ... maybe you know how or where i can get it cheaper .
[doctor] yeah , let's try something else , um ... sometimes it can be cheaper if we just prescribe you the individual ingredients of a medication , rather than the , the combined medication itself .
[patient] that would be great .
[doctor] so , that's clindamycin gel and benzoyl peroxide , uh , maybe by doing them separately , they could be a lot cheaper . so , that we can do . the unithroid , with the discount code , should only be about $ 9 for 90 days .
[patient] okay , that would be great . yeah , they were charging me $ 75 , and i just could n't pay that .
[doctor] maybe we'll try different pharmacy , as well .
[patient] okay . so , do you think that my weight gain could have been the birth control that i was taking before that caused it ?
[doctor] maybe . i do n't really see an endocrine cause for it , at least , so i would need to see the , the hyperandrogynism or high testosterone . or , a high dhea , to cause acne , or hair growth , or any of that stuff . but , the numbers are n't showing up out of range .
[patient] okay .
[doctor] i really do n't see any endocrine cause for it , like i said . your growth hormone was fine , but we definitely want to and need to treat it . um , i do n't know if we talked about maybe a little weight loss study .
[patient] you mentioned the weight loss study , and you mentioned that i have some meal plans , um , that you had given me . i still have those , too .
[doctor] have you tried to make any changes in the diet since the last time we spoke ?
[patient] i've been trying to get better . i will start back at the gym in july , because of my contract , i had to put a hold on it until then .
[doctor] okay .
[patient] so , i do want to start doing that . i will be a little freer since , um , i'll be on vacation after july 8th .
[doctor] okay , good .
[patient] and then my cousin was telling me to ask you about cla , because it's supposed to help your metabolism . is that okay to take ?
[doctor] um , i'm not sure . what is c , cla ?
[patient] i'm not sure what it is , either .
[doctor] okay , well , i'm unfamiliar with it , so ...
[patient] okay . i also have a coworker who has a thyroid issue too , and she suggested to try chromium for weight loss .
[doctor] so , that likely will not help too much . you can try either , if you really want to , but then ... it will not accept you into the weight loss study if you try those two .
[patient] okay .
[doctor] chromium is just a supplement and it wo n't help that much .
[patient] it wo n't , okay , thank you .
[doctor] it wo n't hurt ... okay , i should n't say that it wo n't hurt , but , it also wo n't help that much . so , it's up to you .
[patient] okay . and so , my cousin also suggested amino acids , and that i might find them in certain foods , i guess , for my workout .
[doctor] yeah . amino acids are fine , they wo n't , wo n't really help with weight loss either , but it might help , uh , you replenish , and just kind of , feel hydrated .
[patient] okay . are they proteins ? um , my cousin said she had lost some weight , and has been working out every day , but she does n't work , so ... i do n't know .
[doctor] yes , amino acids are what make up the protein , which is in any food you eat , with any protein . so , meats , dairy , nuts , any of that sort of thing .
[patient] okay , thank you . got it .
[doctor] all right . um , are you allergic to any medications ?
[patient] no , not that i know of .
[doctor] okay . is your s- skin pretty sensitive ?
[patient] yes .
[doctor] all right .
[patient] um , yeah , my size , i will start getting rashes , with different products .
[doctor] and have you ever tried clindamycin topical , as an antibiotic for your acne ?
[patient] no , i've never tried anything for it .
[doctor] okay . we might give you some of that .
[patient] okay . and i also want to mention that my feet do swell up a lot .
[doctor] okay . i'm ... let me take a look at that for just a moment . um , any constipation ?
[patient] yes , i also do have that problem .
[doctor] all right . mira- miralax will definitely help with that .
[patient] okay , yes , my doctor did also recommend that .
[doctor] great . all right , let's do an exam real quick . please have a seat on this table and i'll listen to your lungs and heart .
[patient] okay .
[doctor] all right , deep breath . all right , again .
[patient] okay .
[doctor] all right , sounds good .
[patient] great .
[doctor] let me take a look at your feet and ankles .
[patient] okay .
[doctor] all right , they look okay right now , certainly let your doctor know about this if it gets any worse or reoccurs .
[patient] okay , i will do that .
[doctor] now , let's go over your lab work . so , when you took that pill , the dexamethasone test , you passed , which means you do n't have cushing's syndrome . on that test , at least . the salivary cortisol , though , unless you did one wrong ... two of them were completely normal and one was abnormal , so , we might need to repeat that in the future .
[patient] okay , that's okay .
[doctor] all right , so , your cholesterol was quite high . the total cholesterol was 222 . the good cholesterol was about 44 . the bad was 153 , and it should be less than 100 . the non-hdl was about 178 , and it should be less than 130 . the good cholesterol should be over 50 , and it was 44 . so , your screen for diabetes is ... was fine . you do have a vitamin d deficiency , and , i do n't know if we started the vitamin d yet , or not .
[patient] yes , we did . i- i do need to take one today , though .
[doctor] okay . so , i also checked a lot of other pituitary hormones , iron levels ... everything else seemed to be pretty good , and in decent range .
[patient] okay , that sounds great . so , i wanted to also show you my liver enzymes , um , because i have n't come back since then ... but i was also happy , because one of them was back to normal .
[doctor] okay , great . let's see them .
[patient] okay . so , the one that's 30 , that was almost 200 not so long ago .
[doctor] yeah , your alt was about 128 .
[patient] okay , and , and back in october was 254 .
[doctor] yeah , this is much better .
[patient] okay , great . and then it dropped in january , and then it dropped a little more in march , since i stopped taking the medicine in december .
[doctor] okay , that's good . so ... i'm proud of you with the course of your labs , so before i forget , i'm going to , uh , just put your labs into the computer today , and i wo n't be checking your vitamin d level for some time .
[patient] okay . so , with the thyroid , and the low vitamin d , does that always happen together ?
[doctor] um , i do have a lot of people that have thyroid , thyroid issues and they have vitamin d deficiency .
[patient] okay .
[doctor] this is what i'm , um , i'm going to do . i'm going to put , print out your prescriptions , so you can shop around at the pharmacies and see if you can find better prices .
[patient] okay , that way i can go ask them and try cvs .
[doctor] yeah , that sounds like a plan .
[patient] okay , good . so , the weight loss study that you mentioned , when does that start ? or , how does that work ?
[doctor] so , we are about to start , as we just got approval last week , and we are just waiting on our paperwork so we can get started .
[patient] okay , and what's involved with that ?
[doctor] so , it'll involve you receiving a medication which has been used for diabetes treatment , and it works mostly in the gut on satiety , or satiety hormones . um , the most common side effects are going to be nausea , vomiting , diarrhea and constipation . they are s- uh , six arms , to the study . one is a placebo , the other ones are a , various as ... various dosages of the medication , excuse me . um , you would receive an injection once a week . also , keep in mind that most of the weight loss medications are not covered by insurance .
[patient] okay .
[doctor] so , it's a way of getting them , but , the odds of getting one of the arms with the medication that are in your favor , right , might be only one out of five of our hundred patients that we have on the list for the study that will receive the placebo .
[patient] okay .
[doctor] does that make sense ?
[patient] yes , it does .
[doctor] so , we do expect pretty big weight loss , because of what we learn in diabetes study . so , it's a year long , uh , process , and it's an injection once a week . you come in weekly for the first four , five weeks , i believe . and then , after that , it's once a month . you do get a stipend for partici- for participating in the study , and parking is validated , and whatever else that you need for the study .
[patient] okay , do you know how much the stipend is ?
[doctor] um , i will have to double check for you , and , you do n't have to be my patient , you just have to meet the criteria . so the criteria is a bmi greater than 30 , if you do n't have any other medical condition . or , a bmi greater than 27 , if you do have another medical condition , like your cholesterol . um , a bmi greater than 27 would quali- uh , qualify you .
[patient] i have a friend who might be interested , and she does have diabetes .
[doctor] if she has d- diabetes , then she wo n't qualify .
[patient] okay , you ca n't if you ... if you have diabetes , got it .
[doctor] correct . yeah , the only thing that , um , they can not have , really , is diabetes . so , either a psychiatric disease , or schizophrenia , bipolar , things like that .
[patient] okay .
[doctor] but , if they have hypertension , high cholesterol , things like that ... they can definitely sign up .
[patient] and they can , okay . thank you for explaining that .
[doctor] of course . so , do you want me to try to get you into that study ? or , would you just like to try , me to prescribe something ? it's kind of up to you .
[patient] i think i'll just wait for a little bit now .
[doctor] all right , sounds good . i'll give you the information for the research , it's just in my office . um , it is a different phone number , though . so then , if you're interested , just call us within a month , because i do n't know how long , uh , the , the wait will be .
[patient] okay , will do .
[doctor] perfect . so , let me go grab your discount card for the unithroid . um , when you go in to activate it , the instructions are on this card , and then you use your insurance ... then , show them this , and ask how much it'll cost . if it's too expensive , just let me know .
[patient] i will . thank you so much for your help on that .
[doctor] you're welcome . then , what i did is , i gave you a topical antibiotic , plus i gave you the benzoyl peroxide . so , the peroxide may bleach your sheets , but , you want to make sure to take it and apply it at night , so you do n't have a reaction from the sun during the day .
[patient] okay , i can do that .
[doctor] but , you do also want to make sure that you do n't mess up your sheets .
[patient] okay , sounds good .
[doctor] um , so , that's that . and then , let's see how you do on the other medications . i think this will , this will get better . in the meantime , a low-carb diet , avoid alcohol and fatty foods , and low chole- cholesterol foods .
[patient] okay .
[doctor] and again , once you finish your dose of vitamin d , for the vitamin d deficiency , you're gon na start with the 2000iu daily , so that you're able to maintain those levels . sound good ?
[patient] yes , that sounds great .
[doctor] i really think your liver enzymes are going to get better once you lose the weight , though .
[patient] okay , that would be great .
[doctor] since we stopped your birth control , we can try once called phexxi , which is kind of like a spermicide , basically .
[patient] okay .
[doctor] and you just apply it before intercourse .
[patient] okay .
[doctor] if you need some , uh , just let me know .
[patient] okay , i will . i'll let you know .
[doctor] okay , perfect . so , stay put for me now . i'm going to go see if they have discount samples , and bring you that prescription . and then , i'm going to order the labs for next time .
[patient] okay , great , thank you so much .
[doctor] you're welcome .
[doctor] so , under the plan , under abnormal liver enzymes , they have improved since discontinuation of her birth control . under abnormal weight gain , her dexamethasone suppression test was normal . two out of three salivary cortisol tests were normal , not consistent with cushing's , and therefore we're ruling out cushing's . under her hirsutism , her androgen levels were normal . for the acne vulgaris , the epiduo was not covered , so we'll try benzoyl peroxide with clindamycin , and remove the previous information . on the hyperthyroidism , we'll print out her prescriptions . unithroid should be better priced with the discount card , and we'll repeat levels of everything before next visit . thanks .

Medical orders:
description: phexxi apply it before intercourse
order_type: medication
description: liver enzymes
order_type: lab
reason: abnormal liver enzymes
description: apply it at night benzoyl peroxide
order_type: medication
reason: acne vulgaris
description: topical clindamycin
order_type: medication
reason: acne vulgaris
description: total cholesterol
order_type: lab
reason: cholesterol was quite high
description: next visit
order_type: followup
description: screen for diabetes
order_type: lab
description: pituitary hormones
order_type: lab
reason: hyperthyroidism
description: iron levels
order_type: lab
description: vitamin d 2000 iu daily
order_type: medication
reason: vitamin d deficiency