[doctor] um , hi mrs. anderson . right ? [patient] yeah . yes , doctor . [doctor] what brings you here today ? [patient] hi , doctor . um , i'm having this left shoulder pain lately , uh , and it's paining a lot . [doctor] okay . all right . hey , dragon . i am seeing mrs. anderson , a 44-years-old female , uh , complaining to check the left shoulder pain . um , so how long how has this lasted ? [patient] it's been a week , doctor . yeah . [doctor] a week . [patient] yeah . [doctor] um , did you take any medication yourself ? [patient] no , i did not take any pain medications . actually , i did . i did take a tylenol for two or three days , but then that did n't help at all . so , uh , the reason why it started or when it started to happen is- [doctor] yeah . [patient] . i was actually in gymnastics class . [doctor] yeah , okay . [patient] and , uh , i do n't know . maybe i must have toppled over into some weird position , so it started to pain since then , uh , because of a certain move . [doctor] okay , uh- [patient] i went overboard , i think . yeah . [doctor] all right , lem me , uh , take a quick look . uh , can you move up a little bit ? yeah . [patient] uh , yeah . in fact , that's hurts . [doctor] does that- does it hurt ? [patient] yeah , it does . [doctor] what if you move back a little bit ? [patient] uh , that also hurts , doctor . [doctor] yeah , okay . [patient] any kind of movement on my left shoulder actually hurts . [doctor] okay . all right , um , so let's ... hey , dragon . show me the last x-ray . all right , from the x-ray , it does n't look like there is any , uh , broken bone or fracture . my guess is you probably , um , hurt your joint , uh- [patient] uh- . [doctor] . a little bit . [patient] mm-hmm . [doctor] so i would , uh , suggest you continue using the pain reliever , maybe just like 600 milligram of ibuprofen three times a day and use it for a week . [patient] and for how long ? yes . [doctor] for a week . [patient] a week , okay . [doctor] and then if you ... if it's still painful , you can use , uh , ice or , um , heat pad- [patient] okay . [doctor] . 'cause that might help relieve your pain . [patient] okay . [doctor] um ... [patient] but i wanted you to know that i did have past surgery on my , um , left arm- [doctor] mm-hmm . [patient] . so , um , i hope that should n't matter , right ? [doctor] um , that does n't seem related to your pain . [patient] okay . [doctor] so ... but i would try to rest my , your left arm- [patient] okay . [doctor] . while it's healing . [patient] okay . [doctor] so , um- [patient] can i , uh , carry any heavy weights or- [doctor] no , no . definitely not . [patient] . anything like that ? [doctor] definitely not . [patient] okay . okay . [doctor] yeah , use , um , right hand- [patient] okay . [doctor] . instead- [patient] mm-hmm . [doctor] . for the next , uh , at least just three to four weeks . [patient] mm-hmm . [doctor] uh , come back to see me if the pain , you know , still there after maybe three weeks- [patient] sure . [doctor] . so we can take a further look . [patient] okay . sure . [doctor] but you should be fine- [patient] yeah . [doctor] . after just resting and regular pain reliever . [patient] okay . all right . [doctor] um- [patient] should we take another x-ray when i come back , if the pain does n't improve ? [doctor] um , maybe . let's see how you're doing in the next three weeks . [patient] uh . [doctor] hey , dragon . um , order medications and procedures as discussed . all right . [patient] okay . [doctor] um , i think that's good for today . hope you feel better soon . [patient] okay . thank you , doctor . [doctor] yeah . [patient] hopefully , the pain reliever , uh , ibuprofen actually helps . [doctor] yeah . [patient] yeah , and if i have more pain , can i call you ? can i fix up another appointment earlier than three weeks ? [doctor] um , you can also try advil . [patient] okay . [doctor] yeah , so , um ... [patient] yeah . [doctor] ale- , aleve . i mean , aleve . [patient] i see . okay , thank you , doctor . [doctor] thank you .

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended taking ibuprofen 600 mg three times per day for one week. If the patient does not have relief from the ibuprofen she will take Aleve. The patient may also utilize ice or heat packs. She should rest her left arm and may not lift or carry heavy objects with her left arm. The patient should follow up in three to four weeks if the pain persists. We may repeat the left shoulder x-ray at that time.
 "


[doctor] hi , ms. brooks . i'm dr. baker . how are you ? [patient] hi , dr. baker . [doctor] is your , is your right finger hurting ? [patient] yes . [doctor] okay . hey , dragon , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened . [patient] well , i was skiing over the weekend- [doctor] okay . [patient] . and as i was , um , coming down the hill , i tried moguls , which jumping over those big hills , i tend to get my strap caught on my finger- [doctor] [patient] . and it kind of bent it back a bit . [doctor] okay . [patient] yeah . [doctor] and when did this happen ? [patient] it happened , uh ... that was sunday . [doctor] okay . and have you tried anything for this or anything made it better or worse ? [patient] i tried , um , putting ice on it . [doctor] okay . [patient] uh , and then i- i've been taking ibuprofen , but it's still very painful . [doctor] okay . and , uh , is it worse when you bend it ? or anything make it ... so , just wh- [patient] yeah , movement . [doctor] okay . [patient] yes . [doctor] okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ? [patient] um , i have been suffering from constipation recently . [doctor] okay . all right . and do you take ... what medicines do you take for constipation ? [patient] um , i've just been taking , um , mel- um ... [doctor] miralax ? [patient] miralax . that's it . [doctor] okay . miralax is sufficient . [patient] miralax . yes . [doctor] and any surgeries in the past ? [patient] i did have my appendix taken out when i was 18 . [doctor] okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ? [patient] no . [doctor] okay . and how'bout right there ? no ? [patient] no . [doctor] right here ? [patient] that hurts . [doctor] all right . uh , can you bend your finger for me ? [patient] yeah . [doctor] all right . and how about extend it ? all right . and can you touch your thumb with it ? [patient] yes . [doctor] all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have some pain flexion as well . so , let's look at your x-rays . hey , dragon , show me the x-rays . [doctor] all right . so , on this x-ray. everything looks normal right now . uh , i do n't see any fractures . everything lines up pretty well . uh , so , your x-ray looks normal with no fractures . so , based on the x-ray and your exam , you have some tenderness right here . i think you've got a little contusion right here . there's no fracture on the tip of your finger . uh , so , the diagnosis would be a right hand , uh , index finger contusion on the tip of your finger , okay ? so , i would recommend we get you a s- uh , aluminum foam splint and we'll get you some motrin . uh , we'll give you 600 milligrams every six hours and we'll take that for about a week . and if it does n't get better , why do n't you call us and come back at that point ? [patient] okay . [doctor] okay . do you have any questions ? [patient] no . i think that sounds good . [doctor] okay . hey , dragon , order the medication and procedures we discussed . all right . and why do n't you come with me and we'll get you signed out . [patient] okay . thank you . [doctor] all right . finalize report , dragon .

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. She will take Motrin 600 mg every 6 hours for a week. If she does not improve, she will follow up with me. All questions were answered.
 "


[doctor] hi virginia how're you today [patient] i'm good thanks how are you [doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened [patient] i was playing basketball and jerry ran into me and the inside of my knee hurts [doctor] okay did you fall to the ground or did you just kinda plant and he pushed and you went one way and your knee did n't [patient] i did fall to the ground [doctor] you did fall to the ground okay and did you land on the kneecap i mean did it hurt a lot were you able to get up and continue on [patient] i landed on my side i was not able to continue on [doctor] okay so you get off the off the court is jerry a good player you just got ta ask that question [patient] not really [doctor] no [patient] he does n't have much game [doctor] okay okay well you know i love basketball i'm a little short for the game but i absolutely love to watch basketball so it's really cool that you're out there playing it so tell me about a little bit about where it hurts [patient] on the inside [doctor] on the inside of it okay and after the injury did they do anything special for you or you know did you get ice on it right away or try anything [patient] i had ice and an ace wrap [doctor] you had ice and what [patient] an ace wrap [doctor] and an ace wrap okay now how many days ago was this exactly [patient] seven [doctor] seven days ago okay yeah your right knee still looks a little swollen for seven days ago so i'm gon na go ahead and now i also see that you're diabetic and that you take five hundred milligrams of metformin twice a day are you still you're still on that medication is that correct [patient] correct [doctor] and do you check your blood sugars every morning at home [patient] every morning [doctor] okay great and since this i'm the reason i'm asking all these questions i'm a little concerned about the inactivity with your your knee pain and you know how diabetes you need to be very you know active and and taking your medicine to keep that under control so you know may wan na continue to follow up with your pcp for that diabetes as we go through here and just watch your blood sugars extra as we go through that now i'm gon na go ahead and examine your your right knee and when i push on the outside does that hurt at all [patient] no [doctor] okay and when i push on this inside where it's a little swollen does that hurt [patient] yes [doctor] yeah okay i'm just gon na ask a question did you hear or feel a pop in your knee when you were doing this [patient] i did not no [doctor] you did not okay okay what are you doing for the pain today [patient] some exercises ice and mobic [doctor] okay okay so i'm gon na continue all of my exam when i go ahead and pull on your knee the first thing i'm looking at is i do see some ecchymosis and swelling on the inside of that right knee and when i push around that knee i can see that there is fluid in the knee a little bit of fluid in the knee we call that effusion so i can appreciate some of that effusion and that could be either fluid or blood at this point from the injury that you had now you do have pain with palpation on the medial aspect of that right knee and that's that's concerning for me when i'm gon na just i just wan na move your knee a little bit it does n't look like when i extend it and flex it that you have a full range of motion does it hurt a lot when i moved it back a little more than normal [patient] yes it hurts [doctor] okay okay yeah so you do have some decreased range of motion in that right knee now i'm just gon na sit here and and lay you back and i'm gon na pull on your knee and twist your knee a little bit okay you currently there is a negative varus and valgus stress test that's really important so here's what i'm thinking for that right knee i think you have may have a medial collateral ligament strain from you know maybe the twisting motion be right before you fell to the ground i want you to continue to use an ace wrap i'm gon na give you a right knee brace we're gon na wear that for a few days and then i'm gon na send you to physical therapy so we can continue strengthening the muscles around the right knee now that x-ray as far as the x-ray results that x-ray that i did it this morning in the office the the bony alignment's in good position i do n't see any evidence of any fractures i do notice the the effusion around the right knee just a small amount of fluid but we're just gon na continue to watch that i'm gon na give you a prescription i'd like you to stop taking any of the nonsteroidals that you're taking the motrin or advil whichever one of those and i'm gon na give you meloxicam fifteen milligrams and i want you to take that daily for the pain and swelling i want you to just continue exercising with the the braces and everything on so if you can you can get out and do some light walking that'll be good and then again for your diabetes like i said just continue to watch those blood sugars daily and if you start to see any significant increase in them because of your loss of activity just reach out to your primary care physician now do you have any questions for me [patient] when can i play basketball again [doctor] yeah that's a great question i'm gon na ask well my first off i want to see you back here in in seven days you know in a week i want you to make an appointment we're gon na relook at it we're gon na determine if that swelling got any worse and if we need to go on to potentially ordering like a cat scan or an mri of that knee to look and see if there was any significant damage to the ligament so that's for for sure for seven days you're not gon na be playing basketball now are you in a ligue or is that just you get like pick up basketball [patient] i just played the wife with fun [doctor] okay okay good that's a great activity like i said i wish i could play now i i also know your your family do n't they own that sports store down right off a main street that sells a lot of sporting equipment [patient] yeah they do [doctor] okay i you know i'm i'm just thinking you know i need to get some new shoes for some of it my activities i love the i wish i could play basketball but i do a lot of bike riding so i'm always looking for anything that's gon na help me on the bike do you does your family have supplies like that [patient] we do let me know and i can get you the hook up [doctor] okay great great so i'll i i will let you know i'll just get on and take a look first but i'm gon na go ahead and get get you discharged i'll have my assistant come in we will get you discharged and like i said we will make an appointment for seven days and we will go from there any questions [patient] i think you've answered them all thank you [doctor] okay great

ASSESSMENT

Right knee pain, possible medial collateral ligament strain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have prescribed the patient meloxicam 15 mg once a day to treat the pain and swelling. She was advised to stop taking any anti-inflammatory such as Motrin or Advil. I have also recommended that the patient attend formal physical therapy to strengthen her right knee. I have also advised her to continue to use the ACE wrap and wear a right knee brace for a few days. She should continue light walking with her brace on. The patient was advised to stop basketball until she follows up in 7 days.

 Regarding her diabetes, she should continue to monitor her blood sugars daily. She should reach out to her primary care physician if she sees an increase in her blood sugars due to loss of activity.


[doctor] how are you doing [patient] i'm doing i'm good i'm i'm doing really good i'm here i'm just ready to quit smoking and but i've been having quite a hard time with it [doctor] well i'm glad that you're taking the first steps to quit smoking would you tell me a little bit more about your history of smoking [patient] yeah so i've been smoking for some time now i started in high school and was just you know just experimenting and smoking here and there with friends or at parties and then it just started getting more regular and regular and i do n't even know how i'm 44 now and i'm smoking everyday so yes now i'm up to a pack and a half a day [doctor] okay do you use any other type of tobacco products [patient] no smoking is enough [doctor] okay and i understand that so when you wake up in the morning how soon after waking up do you smoke your first cigarette [patient] i would say probably within an hour of waking up i'll have my first cigarette [doctor] okay so i'm really excited that you wan na quit and i know that you probably heard this multiple times before but this really is one of the best things that you can do to help your health especially since you have the history of gout and type two diabetes this is really gon na be a great step in you having better long term health outcomes [patient] yeah i know and you know i'm really motivated now because i am about to be a father any day now and i just really wan na be there for my daughter growing up [doctor] hey that's great and that's great to hear congratulations i'm so excited to hear about the new baby [patient] yeah [doctor] i i have a daughter myself have have you picked out any names [patient] we're you know we're deciding between a few names but we're kinda just waiting to see her to see which name fits [doctor] okay alright that sounds good well congratulations again i'm very excited for you and your and and your wife that that's this is great [patient] thank you [doctor] so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried [patient] yeah actually i just went cold turkey one day i woke up and i said you know i've had enough and i know that smoking is not good for me so i woke up and stopped and i actually did really well and i was able to quit smoking for almost a year and then things just started getting really stressful at work they started laying people off and i'm happy i still have a job but that also meant that i was responsible for more things so things just got stressful and i and just started picking it up again [doctor] well you are absolutely correct you know stress can often be a trigger for things like smoking and drinking have you thought what you would do this time when you encountered the stressful situations [patient] yeah i i did n't think about that a lot actually and one thing is i have started learning and trying to do more meditation and then i also just recently joined the gym so i'm really looking forward to working out again [doctor] okay well that's great to hear that you're getting back in the gym that will be good for your long term health too you know helping to maintain that type two diabetes you know those are really great strategies talking about gym for stress relief and and you know we have other products as well that you can use for an additional aid to help you stop smoking have you given any thought to using some type of smoking cessation aid at this time or or what do you think about that [patient] you know i've had you know because i've been trying to do cold turkey and it's not working and some of my friends actually have mentioned using a patch and they they've had some success with that so i think i would i would probably wan na start with that [doctor] okay alright that that sounds good it's good that you've you've picked out one of those aids and have you thought of a quit date i mean we we really wan na talk about when you're gon na say this is the day [patient] yeah you know next monday is actually my birthday so i think that's a good day [doctor] that's a fantastic day and happy birthday coming up on monday [patient] thank you [doctor] so let's talk a little bit about your exam here okay i'm gon na go ahead and do a quick physical exam and i reviewed your vitals and everything looks good including your oxygen saturation blood pressure for today was one twenty eight over eighty eight heart rate was sixty eight respirations were sixteen and your pulse ox was ninety eight percent on room air so those were all really good now on your heart exam you do have a nice regular and your your rate is of regular rate and rhythm or i'm sorry your heart exam for your heart exam notice that your heart is regular in rate and rhythm i do however still appreciate that two over six systolic murmur that we talked about in the past now that's okay we'll just continue to monitor that now for your lung exam i'm gon na go ahead and listen to your lungs your lungs are clear and equal bilateral with no expiratory wheezes and no rales or rhonchi are appreciated on your neck exam i do n't appreciate any lymphadenopathy when i listen i do n't hear any extra noises so i do n't hear any hearing any carotid bruit which is a good thing now for my impression and plan let's talk a little bit about my assessment and plan for you so for your first problem of nicotine dependence first of all i just want to apply you on making this first step to stop smoking and i want you to know with absolute one hundred percent certainty that i'm gon na be with you every step of the way i think it's fantastic that you're very welcome i i i think it's fantastic you've chosen next monday as a quit date and on that day i'm gon na start you with a twenty one milligram nicotine patch and the goal will be to decrease that over time okay now we will work together to decrease that so there is no necessarily hard dates in mind okay be sure to change the patch location each day and that's going to help reduce or avoid that skin irritation that can occur if you use the same location over and over again i would like to see you again in two weeks just to see how things are going and we will reevaluate at that time the dosage for your nicotine patch now we also see further need to discuss any handouts you received today for those common smoking triggers i really want you to keep an eye on and monitor your stress level not only about work but also the fact that you are experiencing are going to be be a new father and we really want to watch any stress you will be experiencing around the birth of your new child so please keep an eye on that and let me know how that goes now for now until we meet in two weeks go ahead and keep up your exercise routine i think that's a great plan and just try to monitor your stress and and maybe think about some things like meditation or adding in some yoga and that type of thing to help further work with your your stress levels so do you have any questions for me [patient] no not at this time [doctor] okay so for your other conditions that we talked about briefly your second condition of type two diabetes we'll let's go ahead and continue to maintain that with diet and exercise and we'll just monitor your type two diabetes i am gon na go ahead and order a hemoglobin a1c for your next blood draw since i'll see you in two weeks go ahead and have that done and we will talk about that when you come back in now for your third problem of your history of gout let's go ahead and continue you on your allopurinol and just you know continue to watch those foods that will exacerbate your uric acid levels any other questions about those [patient] no i think that's it thanks so much [doctor] alright sounds good i'll see you in two weeks congratulations on the baby and and we're excited about next monday that's your quit date [patient] alrighty thank you [doctor] you're welcome i'll see you in two weeks thanks bye-bye [patient] alright bye

ASSESSMENT AND PLAN

1. Nicotine dependence.
 - Medical Reasoning: The patient has a long history of smoking cigarettes. He is currently smoking 1.5 packs per day. He is highly motivated to cease smoking as he is preparing to become a father.
 - Patient Education and Counseling: I applaud the patient on making this first step to stop smoking. I reassured him that with absolute 100% certainty that I will be with him every step of the way. I explained to the patient that stress can often be a trigger for smoking. He received handouts today for common smoking triggers. I advised him to be watchful and monitor his stress level, not only regarding work, but also his impending fatherhood. The patient and I discussed coping mechanisms for when he encounters stressful situations. I encouraged him to maintain his gym routine, engage in meditation, and try adding in yoga to help further reduce his stress levels. We discussed additional cessation aids.
 - Medical Treatment: The patient has chosen his birthday, as a quit date. On that day, I am going to start him with a 21 mg nicotine patch, and the goal will be to decrease that over time. We will work together to decrease the dosage of the nicotine patch, so there are not necessarily any hard dates in mind. I recommend he change the patch location each day as that will help reduce or avoid any skin irritation that can occur if he re-uses the same location repeatedly.

 2. Type 2 diabetes.
 - Medical Reasoning: Stable.
 - Patient Education and Counseling: We discussed that continuing to follow a healthy diet and perform regular exercise will help to maintain his blood glucose levels.
 - Medical Treatment: We will continue to monitor his type 2 diabetes. Hemoglobin A1c is ordered to be completed by his next visit in 2 weeks.

 3. History of gout.
 - Medical Reasoning: Stable with medication.
 - Patient Education and Counseling: I advised him to continue to watch for foods that will exacerbate his uric acid levels.
 - Medical Treatment: He will continue his allopurinol.


[doctor] hi , andrew . how are you ? [patient] hey , good to see you . [doctor] i'm doing well , i'm doing well . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ? [patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse . [doctor] okay . all right . um , now , have you had your covid vaccines ? [patient] yeah , both . [doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ? [patient] none whatsoever . [doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ? [patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me . [doctor] okay . and are you coughing up anything ? [patient] not yet , but i feel like that's next . [doctor] okay . and fevers ? [patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself . [doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ? [patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags . [doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ? [patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working . [doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ? [patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part . [doctor] okay and have they been elevated at all since this episode of your- [patient] no . [doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ? [patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control . [doctor] but you're taking your medication ? [patient] yes . [doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so , your vital signs here in the office look quite good . [patient] mm-hmm . [doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ? [patient] sure . [doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ? [patient] mm-hmm . [doctor] hey , dragon . show me the chest x-ray . [doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ? [patient] good . [doctor] hey , dragon . show me the diabetic labs . [doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight . [patient] mm-hmm . [doctor] i'd like to see that a little bit better , around six or seven , if possible . [patient] mm-hmm . [doctor] um , so let's talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid . [patient] mm-hmm . [doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing . [patient] mm-hmm . [doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ? [patient] you got it . [doctor] for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ... [patient] mm-hmm . [doctor] . refer you to psychotherapy , if you think that that would be helpful . [patient] mm-hmm . [doctor] would you like that ? [patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that . [doctor] okay . all right . [doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily . [patient] mm-hmm . [doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ? [patient] okay , sure . [doctor] hey , dragon . order a hemoglobin a1c . [doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day . [patient] mm-hmm . [doctor] and i'm gon na go ahead and order a lipid panel , okay ? [patient] sure . [doctor] do you need a refill of the lisinopril ? [patient] actually , i do . [doctor] okay . hey , dragon . order lisinopril , 20 milligrams daily . [doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months . [patient] okay . [doctor] let me know if your symptoms worsen and we can talk more about it , okay ? [patient] you got it . [doctor] all right . hey , dragon . finalize the note .

ASSESSMENT AND PLAN

Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.

 Upper respiratory infection.
 • Medical Reasoning: I believe he has contracted a viral syndrome. His chest x-ray was unremarkable and he has received both doses of the COVID-19 vaccination.
 • Additional Testing: We will obtain a COVID-19 test to rule this out.
 • Medical Treatment: I recommend he use Robitussin for cough, as well as ibuprofen or Tylenol if he develops a fever.

 Depression.
 • Medical Reasoning: He has been practicing barre classes and is doing well overall.
 • Medical Treatment: I offered medication or psychotherapy, but the patient opted to defer at this time.

 Diabetes type 2.
 • Medical Reasoning: His blood glucose levels have been well controlled based on home monitoring, but his recent hemoglobin A1c was elevated.
 • Additional Testing: We will repeat a hemoglobin A1c in 4 months.
 • Medical Treatment: We will increase his metformin to 1000 mg twice daily.

 Hypertension.
 • Medical Reasoning: He has been compliant with lisinopril and his blood pressures have been well controlled based on home monitoring.
 • Additional Testing: We will order a lipid panel.
 • Medical Treatment: He will continue on lisinopril 20 mg once daily. This was refilled today.

 Follow up: I would like to see him back in approximately 4 months.


[doctor] hi keith , how are you ? [patient] ah , not too good . my blood sugar is n't under control . [doctor] and , uh , so keith is a 58-year-old male here for evaluation of high blood sugar . so , what happened ? ha- have you just been taking your blood sugars at home and noticed that they're really high ? or ? [patient] yeah i've been taking them at home and i feel like they've been creeping up slightly . [doctor] have- ... what have they been running , in like the 200's or 300's ? [patient] 300's . [doctor] they've been running in the 300's ? and tell me about your diet . have you been eating anything to spark- ... spike them up ? [patient] to be honest my diet has n't changed much . [doctor] okay . have you- ... go ahead . [patient] actually it has n't changed at all . much of the same . [doctor] okay and what do you con- consider the same ? are you eating lots of sugar ? like , teas and coffees and- [patient] i do n't take sugar with my tea . [doctor] okay , all right . and how about , um , like any added sugars into any kind of processed foods or anything like that ? [patient] uh , i think most of my sugars come from fruit . [doctor] from what ? [patient] fruit . [doctor] fruit , okay . [patient] yeah . [doctor] all right . um , and have you been feeling sick recently ? have you had any fever or chills ? [patient] uh , i have not . [doctor] body aches , joint pain ? [patient] uh , a bit of joint pain . [doctor] multiple joints , or just one joint ? [patient] uh , my knee . uh , sorry , right knee to be more exact . [doctor] your right knee ? [patient] yeah . [doctor] okay . and what happened ? [patient] ah , to be honest , nothing much . i just noticed it when you said it . [doctor] okay , all right . um , and how about any nausea or vomiting or belly pain ? [patient] uh , i was nauseous a couple of days back but , uh , that's just because i was sitting in the back of a car . i hate that . [doctor] okay . all right . and no burning when you urinate or anything like that ? [patient] not at all . [doctor] okay . all right . so , um ... you know , i know that you've had this reflux in the past . how are you doing with that ? are you still having a lot of reflux symptoms or do you feel like it's better since we've put you on the protonix ? [patient] i think it's a bit better . uh , i do n't get up at night anymore with reflux and that's always a good thing . [doctor] okay , all right . and i know you have this history of congestive heart failure . have you noticed any recent , uh , weight gain or fluid retention ? [patient] um , not really . [doctor] no ? okay . um , and any problems sleeping while laying flat ? [patient] uh , i- i prefer to sleep on my side so i ca n't really say . [doctor] okay , but even then , you're flat . [patient] yup , yeah . [doctor] okay . all right . and i know that we had an issue with your right rotator cuff , is that okay ? [patient] it's surprisingly good now . [doctor] okay , all right . all right , well let's go ahead and we'll do a quick physical exam . so ... feeling your neck , i do feel like your thyroid's a bit enlarged here . um , your heart is nice and regular . your lungs are clear . your abdomen , um , is nice and soft . your right knee shows that you have some erythema and- and an insect bite with associated fluctuants . and , um , you have some lower extremity edema on the right hand side . so let's go ahead and look at some of your results . i know the nurse had reported these things and we ordered some labs on you before you came in . hey dragon , show me the vital signs . okay , well your- your vital signs look good , which is good . hey dragon , show me the lyme titer . okay , so , you know , your lyme titer is a little elevated , so i think we'll have to go ahead and- and look into that a little bit , okay ? [patient] makes sense . [doctor] that can certainly cause your blood sugar to be elevated . um , hey dragon , uh , show me the rapid strep . and you also have , uh , positive for strep . so i think we have some reasons as to why your blood sugar is so high . so my impression of you , you know , you have this hyperglycemia , which is probably related to some infections going on in your body . um , from a- a- a rapid strep standpoint we're gon na go ahead and treat you with penicillin or , i'm sorry , amoxicillin , 500 milligrams , three times a day . uh , make sure you take it all , even if you start feeling better , okay ? [patient] for sure . [doctor] hey dragon , order amoxicillin , 500 milligrams , three times a day for 10 days . um ... okay . and from ... , and from all- ... a positive lyme titer aspect , we should go ahead and order a western blot , just pcr to see if you have any , um , to see if it's actually acute lyme , okay ? [patient] okay . [doctor] okay . um , hey dragon , order a western blot pcr for lyme . okay . all right . well we'll go ahead and , um , the nurse will come in soon and she'll set you up with these tests , okay ? [patient] yeah . you said lyme . is that related to lyme disease ? [doctor] yes it is , yeah . [patient] you're certain i do n't have alpha-gal syndrome though , right ? i'm terrified of that one . [doctor] have what ? [patient] alpha-gal syndrome , the one where a tick bites you and you get an allergic reaction to meat . [doctor] yeah , i do n't think so . have you eaten meat over the last couple of days ? [patient] i have . [doctor] okay . well i- ... it's , you know , your blood sugar's elevated so you might be having an inflammatory response to that , but we'll go ahead and order some tests to look into it , okay ? [patient] that sounds good . [doctor] all right . call me if anything happens , okay ? [patient] definitely . [doctor] all right . hey dragon , finalize the note .

ASSESSMENT AND PLAN

The patient is a 58-year-old male who presents for evaluation of high blood sugar.

 Hyperglycemia
 • Medical Reasoning: This is likely related to an inflammatory response as the patient had an elevated Lyme titer and positive rapid strep test.
 • Additional Testing: We will order a western blot PCR to evaluate for Lyme disease.
 • Medical Treatment: We are going to treat him with amoxicillin 500 mg 3 times a day for 10 days.


[doctor] hey , ms. james . nice to meet you . [patient] nice to meet you , dr. cooper . how are you ? [doctor] i'm well . hey , dragon , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ? [patient] i hurt my , uh , finger when i was skiing this past weekend . [doctor] really ? [patient] yeah . yeah , so , um , i was going down hill , double diamonds , uh , double black diamonds , and i just lost control , and i , you know , flipped down a few ways , but , uh , somewhere along the way , i , i jammed my , my index finger on something . i'm not sure what . [doctor] okay . so this happened last saturday , you said ? [patient] it was saturday , yes . [doctor] okay . so about five days of this right index finger pain . [patient] mm-hmm . [doctor] have you taken any medicine for it ? [patient] i took some ibuprofen . um , did n't really seem to help . [doctor] okay . have you iced it or put a splint on it ? [patient] no . [doctor] okay . and what would you rate your pain ? [patient] it's about a seven . [doctor] a seven out of 10 pain . um , and no other injuries while you went down this double black diamond ? [patient] no , interestingly enough , this is the only one . [doctor] okay . well , i guess you escaped ... i mean ... [patient] could have been much worse . [doctor] could have been much worse , yes . so , um , do you have any medical problems ? [patient] um ... yeah , i'm ... i have chronic constipation . [doctor] do you take any medicine for it ? [patient] miralax . [doctor] and does that help ? [patient] seems to flow nicely . [doctor] good for you . [doctor] um ... have you ever had any surgeries before ? [patient] yes , i had my appendix out when i was seven . [doctor] okay . um , let's look at your x-ray together . hey , dragon , show me the last x-ray . all right . so looking at your right hand here , and that index finger looks great . so all the joints , bones are in the right places , no fractures , so you've got a normal right hand x-ray . um , let's go ahead and check your finger out . now does it hurt when i push on your finger like this ? [patient] yes . [doctor] does it hurt when i pull your finger like this ? [patient] yes . [doctor] does it hurt when i squeeze over this joint here ? [patient] yes . please do n't do that . [doctor] does it hurt when i squeeze over this ? [patient] yes . [doctor] okay . um ... so with your x-ray , and with your exam , looks like you have a sprain of your distar- distal interphalangeal joint . it's called your dip joint , of your right index finger , and so what we're gon na do for that is we're gon na put a splint on that right finger . i'm gon na give you a strong antiinflammatory called mobic . you'll take 15 milligrams once a day . i'll prescribe 14 of those for you . and i want you to come back and see me in two weeks , and let's make sure it's all healed up and if we need to start any hand therapy at that point , then we can . do you have any questions for me ? [patient] no questions . thank you . [doctor] you're welcome . hey , dragon , order the medications and procedures mentioned . and why do n't you come with me , and we'll get you checked out ? [patient] okay . [doctor] hey , dragon , finalize the report .

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. A prescription is provided for Mobic 15 mg once a day, dispense 14. She will follow up with me in 2 weeks for a repeat evaluation. If she is unimproved, we will consider hand therapy at that time. All questions were answered.
 "


[doctor] judy gomez , mrn 869723 . date of birth , 5 , 7 , 1961 . she's in office today for ongoing management of psoriatic arthritis . hello , judy , how are you doing today ? [patient] i'm doing good , thank you . how are you ? [doctor] i'm great , thanks . so how have you been since the last time ? i know the last time we were talking about decreasing your prednisone dose , correct ? [patient] yes . i'm just on one now and that seems to be enough . [doctor] aw , that's great to hear . [patient] yeah , there were a couple days there i took an extra one , just because there was a little extra pain in my feet . and i do have a desk job , so when i have a day off where i'm moving around a lot they do tend to hurt a bit more . [doctor] okay . how many times did you do that ? [patient] um , it was n't often , maybe once a week . [doctor] okay . so it sounds like we're still on track for discontinuing the prednisone . we'll do that today and you can let me know how it goes on your next visit . and how about the methotrexate , do you think that helped with your joint pain ? [patient] yeah , definitely . because i went to get my covid shots , um , but from the letter i got about it , it said that it could interfere with the vaccine , you know , reduce the efficacy . so i did n't take it on the week that i got the first shot . [doctor] okay . and what happened ? [patient] i felt absolutely horrible until i took it again a week later . [doctor] i'm sorry to hear that . and- and what did you do about the second dose ? [patient] well , i called into the hotline because i was in so much pain with the first one . and they said ,  no , just go ahead and take it ,  so i did . [doctor] okay . that's good then . we do have to keep an eye out on it since it's a high-risk medication . do you have an appointment to get your blood drawn for the next time ? [patient] no , they did n't give me one . [doctor] okay . so we can do that for you too . uhm , so what questions do you have for me , judy ? [patient] well , i just wanted to know why i was getting all these bruises here , so like when i bump myself . i do n't know where they're coming from . [doctor] okay . that's probably from the prednisone , it can increase bruising . [patient] okay . i did n't know that . um , i do n't even feel it when it happens , they just show up . [doctor] yeah . unfortunately that can happen , but we're working on discontinuing that so let's see if the bruises do go away . [patient] okay . that sounds good , thanks . [doctor] okay , judy , please , um , sit up here and i'll take a look . shoes and socks off please . [patient] all right . [doctor] all right . let me see here . okay . so where is it hurting ? in your joints right here ? [patient] yeah , a little . also in my feet joints as well . [doctor] okay . and how about when you bend the knee like this ? [patient] well , it hurt before we increased the methotrexate , but it's doing pretty good now . [doctor] okay , good . can you flex your toes please ? good range of motion . also ridges in nails , that's from the psoriasis . [patient] yeah . they've been like that for a long time now . [doctor] okay . all right , uhm , ms gomez , it looks like we're moving along with your treatment nicely . we'll stop your prednisone and continue with the methotrexate . make sure to stop by the front desk and make an appointment for the blood work , and i'll see you in three months . [patient] all right . it sounds good . thank you so much , it was great to see you . [doctor] it was great seeing you too . thank you .

ASSESSMENT

• Psoriatic arthritis.
 • High risk medication use.

PLAN

Psoriatic arthritis.
 Stable on methotrexate and prednisone 1 mg daily. The patient will discontinue prednisone and continue methotrexate.