[doctor] hi billy how are you what's been going on the medical assistant told me that you're having some difficulty urinating [patient] yeah yeah i i did n't really wan na come in to talk about it's kinda weird but i think probably over the last six months i'm just not peeing right it just does n't seem to be normal [doctor] okay so let's talk a little bit about that now is your is your stream is your urination stream weak [patient] yeah i'd probably say so [doctor] okay and do you feel like you're emptying your bladder fully or do you feel like you still have some urine left in there when you when you finish [patient] most of the times i'm okay but sometimes if i stand there long enough i i can kinda go a little bit more so it's taking a while actually to just go to the bathroom [doctor] okay and are you waking up at night to go to the bathroom does it impact your sleep [patient] yeah i try to empty my bladder now right before i go to bed and and not drink anything but i'm still probably getting up three or four times a night to go to the bed [doctor] okay so you're getting up about three or four times a night and and how long has this been going on you said for about six months [patient] yeah six months to like this and it's probably been a little bit worse over the last six months and maybe it's been longer i just did n't want to bring it up [doctor] okay so you think it's been going on longer okay alright now how about have you had any burning when you urinate at all [patient] no it i do n't think it burns [doctor] no burning when you urinate okay and and any other any other issues any problems with your bowels any constipation issues [patient] hmmm no i i i had diarrhea last week but i think i ate something bad [doctor] okay and ever have you ever had any issues where you had what we call urinary retention where you could n't pee and you needed to have like a catheter inserted [patient] my gosh no [doctor] okay [patient] i'll do that [doctor] alright and have you ever seen a urologist i do n't think so you've been my patient for a while i do n't remember ever sending you but have you ever seen one [patient] i do n't think so [doctor] okay now tell me how are you doing with your with your heart when was the last time you saw doctor moore the cardiologist i know that you had the the stent placed in your right coronary artery about what was that twenty eighteen [patient] yeah sounds about right i think i just saw him in november he said everything was okay [doctor] he said everything was okay alright and so you have n't had any chest pain or shortness of breath you're still walking around doing your activities of daily living are you exercising [patient] kind of [doctor] kind of okay now from what i remember i remember you being a big college football fan are you as excited as i am that georgia beat alabama in the national championships [patient] yeah yeah i'm super excited [doctor] you do n't really seem that excited [patient] get the problem fixed because i have to be able to sit there and watch the whole game [doctor] yeah i i really do n't like nick saving i'm so i'm super happy that that the dogs pulled it out [patient] i do n't know if we can do friends anymore [doctor] are you in alabama fan [patient] maybe i'm actually originally not from georgia so [doctor] okay alright well i mean i i'm i'm a long horns fan but anyway well i digress let's talk a little bit about your diabetes how are how are you doing with your sugars are you watching your diet [patient] i'm trying to yeah i think they are okay [doctor] okay and are you still taking the metformin [patient] yep [doctor] you are okay alright now i wan na go ahead and just move on to a quick physical exam okay i'm gon na be calling out some of my exam findings and i'm gon na let you know what that means when i'm done okay alright i do have to do a rectal exam i apologize i'm just gon na be calling it out what what i what i appreciate okay so on your heart exam i do appreciate a slight three out of six systolic ejection murmur hurt at the left base on your lung exam your lungs are clear to auscultation bilaterally on your abdominal exam your abdomen is nontender and nondistended i do n't appreciate any masses or any rebound or guarding on your prostate exam i do appreciate an enlarged prostate i do n't appreciate any masses on physical exam so what what does that mean billy so that ultimately means that you know everything looks good you know you have that little heart murmur which i believe you you've had in the past but we're gon na go ahead and look into that you know your prostate seems a little bit enlarged to me on physical exam so let's talk about how we can go about and and remedy that okay so for your first problem of this you know difficulty urinating i wan na go ahead and just order some routine labs i wan na get a a psa that kind of that ultimately kinda looks for prostate cancer issues which i do n't think you have because we did n't really appreciate that on physical exam i wan na go ahead and we can try to start you on what we call flomax zero point four milligrams once a day you should take it at night because it can cause people to get a little bit dizzy if they take it in the morning so i would take it at night and i wan na go ahead and refer you to a urologist just to look into this more so we can go ahead and and get this problem solved for you okay i'm also gon na go ahead and just order some routine blood tests just to make sure that we are not missing anything do you have any questions about that and i wan na go ahead and order a urinalysis and a urine culture [patient] yeah so sounds good have you seen that commercial for that super batter prostate stuff does that work [doctor] well i think the data it's it's i'm not really sure if it works or not i'm not that familiar with it let's just go ahead and stick with flomax and that's why we are gon na refer you to the urologist so that they can go ahead and talk to you about you know the most current treatment options for you okay [patient] alright [doctor] alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that [patient] nope [doctor] okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns [patient] alright when is the urologist gon na call me [doctor] i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week [patient] sounds good [doctor] okay alright well great it was good to see you bye [doctor] i could just hit it and i can just talk and then i'm just

ASSESSMENT AND PLAN

1. Difficulty urinating.
 - Medical Reasoning: The patient presents today with approximately a 6 month history of difficulty with urination. His prostate also felt slightly enlarged on exam today.
 - Patient Education and Counseling: The patient was advised that there were no concerning symptoms of prostate cancer appreciated on his physical exam today.
 - Medical Treatment: We will order routine labs including a PSA to rule out prostate cancer. We will also refer him to a urologist for further evaluation as well as order a urinalysis and urine culture. We will start him on Flomax 0.4 mg once at night to avoid dizziness.

 2. Coronary artery disease.
 - Medical Reasoning: The patient had a 3/6 systolic ejection murmur heard at the left base on exam today. This has been heard on his exams in the past.
 - Medical Treatment: We will order an echocardiogram to follow up on his murmur. We will also order a lipid panel. He will continue Lipitor 40 mg a day, aspirin and metoprolol.

 3. Diabetes.
 - Medical Reasoning: The patient is currently doing well with his diabetes.
 - Medical Treatment: We will continue him on metformin 1000 mg twice a day. A hemoglobin A1c will be ordered to see if any medication adjustments are needed.


[doctor] patient's name is diana scott . date of birth , 12/8/1920 . the date of service is 7/9/2021 . this is a new patient note . [doctor] good afternoon . how are you today ? [patient] i'm good , thank you . [doctor] good . well , what brings you in to see me today ? [patient] well , my doctor says that i have a heart murmur . [doctor] okay . [patient] so i do n't know how big a heart murmur i have , or really even what it is . [doctor] okay . so how long have you had that for ? do you have any idea , or is that completely new as far as you know ? [patient] yeah , she said it's a new worrisome heart murmur . so of course , i'm worried as well . [doctor] got it . okay . and are you having any symptoms at all ? [patient] i do n't think so . i do n't know what symptoms i should be having . [doctor] okay . well , so you are 100 , so we ca n't really get around that one . so i expect that you probably do n't move quite as fast as maybe you used to ? [patient] no , i definitely do n't . [doctor] okay . and do you notice that you have any chest pain or f- feel shortness of breath ? [patient] no , i do n't have any chest pain . um , my problem is i have severe pains in my legs , and so she had me going for a chest x-ray , and that was just last week . [doctor] okay . [patient] and so i started taking pain pills for my legs . [doctor] okay , got it , for the legs . and do you feel short of breath at all ? [patient] if i walk too fast or too long , or if i tried to drink a whole glass of water without stopping , then yeah , i do get short of breath that way . [doctor] okay . and how far can you walk before you feel short of breath or sort of overly fatigued ? [patient] well , i do have a walker now , so i do n't know . maybe when i walk to the end of the driveway or i walk around the culdesac . [doctor] got it . all right . [patient] so it is n't that bothersome to me at all . um , maybe more if i try to overdo it . [doctor] okay . [patient] then i , um , i get short of breath if i do overdo it though . [doctor] okay , got it . and so how different would you say , um , that the symptoms are now compared to like six months ago or a year ago ? [patient] i would say probably 70 to 80 % from about six months ago . before that i did n't notice anything at all . [doctor] okay . so do you feel like it's mainly the leg pain that seems to limit you ? [patient] my legs have been severe for about a month now . [doctor] okay . and how about , do you feel lightheaded or dizzy at all ? [patient] yeah . so i do take a pill for that when it does get bad . [doctor] okay . [patient] yeah , and i do n't take it every day , only when i do feel dizzy . [doctor] okay . and so how about any passing out at all ? [patient] no . [doctor] okay , good . and how about irregular heartbeats ? do you ever feel like your heart is going too fast or like it skips a beat ? [patient] i do n't notice it at all . [doctor] okay , great . and how about any swelling in the legs at all ? [patient] yeah , my ankles swell . [doctor] okay . and how long has this been going on ? [patient] um , i would say for probably six months . but it goes up and down , and sometimes it's worse than other times . [doctor] okay . and how about any recent weight gain or anything else like that ? [patient] um , i lost a little bit of weight , but i still weigh a 120 pounds , but i normally weigh about 130 pounds . [doctor] mm-hmm . okay . [patient] um , but that's been going down gradually for about a year . [doctor] okay . and then how about any fevers , chills or anything else that's , that's going on that you can think of ? [patient] no . [doctor] good . so mainly it sounds like you came in , um , mostly because of the murmur . is that right ? and sort of just kind of seeing what things look like ? [patient] yeah , that and i feel overly tired because i take all that medication . [doctor] okay . and so fatigue as well . and have you ever had any testing of your heart done ? [patient] i'm not really sure . [doctor] okay . it does look like you've had a decent number of sh- , uh , surgeries here , ? [patient] yeah , you name it . [doctor] all right . well , i wo n't make you repeat them since i do have a good record . um , but just give me just a second and i'm going to enter the ones we need , okay ? all right . got them . and then , are you taking all the medicines that you went through with madison ? [patient] yes . [doctor] okay , good . and looking at your family history , it looks like maybe your brother had a heart attack . is that correct ? [patient] it was actually my son , not my brother . [doctor] okay , i'll make that adjustment . [patient] um , but my brother did have a stroke . but that was because he had gotten sugar diabetes , and my eldest sister did have a heart problem as well . [doctor] okay , i see . [patient] yeah , so heart problems kinda run in the family . [doctor] okay . all right . well , it looks like also that you never smoked . that's excellent . and then no allergies to medicines that you know of , is that correct ? [patient] correct . [doctor] all right . well , let's do a quick exam . [patient] all right . sounds good . [doctor] all right . well , for physical exam , please use the regular template . all right , please just breathe normally . great . and now take a few deep breaths for me . all right . do you feel okay ? are you feeling any dizziness or anything ? [patient] no , i feel fine . [doctor] okay , great . all right . well , that is it for the exam . [patient] okay . [doctor] all right . so what i'm thinking is , let's go ahead and schedule you for an echocardiogram . it's a very common test and it just takes a picture of your heart . and it'll let me see how well your heart is actually working . [patient] okay . [doctor] and i can order that for today . um , do you have time to complete that ? it should n't take too long . [patient] yes , that's fine . i have time . [doctor] okay , great . so we will complete that today , um , to assess your overall cardiac structure and function , as well as , uh , the valve view of where diseased . [patient] okay . [doctor] and some hospital outcomes and what we might suggest to fix that out , i'll go over that . so one possible suspicion i'm having is it's called , um , aortic stenosis , and that just means that one of your main valves of your heart has narrowed a bit and the valve does n't really open , um , quite fully . and this could just reduce or block the blood flow from your heart into the main artery of your body , and that's called the aorta , into the rest of your body . [patient] okay . [doctor] and if this is severe , then we might wan na perform a procedure called the transcatheter aortic valve replacement , or we just call it tavr . and it is a minimally invasive procedure to replace the valve . [patient] well , i would have to think about that . i'm not too sure i'd wan na do that , given my age of all . [doctor] yeah , sure , no problem . and we do n't have to make any decisions today , just , you know , wanted to go over a couple of these things . um , but sometimes we can also perform a surgical aortic valve replacement , or it's called an savr . but really , because of your age and medical history , um , unfortunately , that would n't be a good option for you . [patient] i see . okay . well , i guess we'll see , um , what you see from , from the , um , test . [doctor] yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently . [patient] okay , good . [doctor] and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able to stop your statin . [patient] really ? [doctor] yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin . [patient] okay , that sounds great . thank you . [doctor] you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them . [patient] okay , i will . [doctor] all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ? [patient] not that i can think of . thank you so much . and i think it looks good . [doctor] okay , awesome . all right . well , have a good rest of your day , and we'll see you soon . [doctor] for physical exam , constitutional elderly otherwise no acute distress . cardiovascular normal s1 and s2 is preserved with a normal rate and regular rhythm . there is a 4/6 systolic murmur at the right upper sternal border with , uhm , mild radiation to the carotids . neurologic gait is normal for age . [doctor] for assessment and plan , probably one cardiac murmur . diana has a 4/6 systolic murmur at the upper right sternal border with mild radiation to the carotids . this is most likely representative of aortic stenosis , for symptoms could be due to severe aortic , aortic stenosis . however , her s2 is relatively preserved , which would be more consistent with , consistent with moderate . some of her outside records do note diastolic dysfunction , so it is possible she , she did have an echocardiogram at some point in the past . she does not appear significantly volume overloaded today . [doctor] her next problem is pvcs . her referral mentioned tachycardia . uh , her ekg today shows sinus rhythm with frequent pvcs , as well as an anterior septum infarct pattern . she does not have any significant palpitations and we will check an echocardiogram to assess overa- overall cardiac structure and function . depending on results as well as the severity of her aortic stenosis , we will need to consider an ischemic evaluation , or further , possibly a heart mon- monitor to assess overall burden of the pvcs . at this point , she's asymptomatic , so we will start with the echocardiogram only . [doctor] her next problem , hypolipidemia , is managed by her pcp . due to bilateral leg pain over the last month , considered tavr evaluation following echocardiogram . statin could be indicated . [doctor] and next problem , lightheadedness , dizziness . she is on meclizine for this . it is possible that some of her lightheadedness and dizziness is related to the aorta stenosis , and we will do an echocardiogram as noted above . pvcs on her ekg could be contributing , but she does not feel palpitations . we will consider a monitor , but start with the echocardiogram first as noted above . follow up three to four weeks after her echocardiogram is done to discuss results and next steps . end of dictation .

ASSESSMENT

• Cardiac murmur.
 • PVCs.
 • Hypertension.
 • Hyperlipidemia.
 • Hypothyroid.
 • Lightheadedness/dizziness.

PLAN

Cardiac murmur
 Diana has a 4/6 systolic murmur at the RUSB with mild radiation to the carotids. This is most likely representative of aortic stenosis. She does have symptoms including a significant increase in fatigue over the last 6 months, shortness of breath, and some lightheadedness. This could be due to severe aortic stenosis, however, her S2 is relatively preserved which would be more consistent with moderate. She is unsure if she has had an echocardiogram, although some of her outside records do note diastolic dysfunction, so it is possible that she had one as some point in the past. We will order a repeat echocardiogram today to assess overall cardiac structure and function as well as valvular disease. If she does truly have severe aortic stenosis, I briefly discussed a TAVR procedure today as she is not a candidate for a surgical AVR given her age co-morbidities and frailty. She is unsure if she would be interested in this, but we will assess first with the echocardiogram and then discuss further at follow-up. She does not appear significantly volume overloaded today.

 PVCs
 Her referral mentions tachycardia. Her EKG today shows sinus rhythm with frequent PVCs as well as anterior septal infarct pattern. She does not have any significant palpitations. We will check an echocardiogram to assess overall cardiac structure and function. Depending on results as well as the severity of her aortic stenosis, we will need to consider an ischemic evaluation or possibly a heart monitor to assess the overall burden of PVCs. At this point, she is asymptomatic, so we will start with the echocardiogram only.

 Hypertension
 She is taking amlodipine and lisinopril. We will continue these as is.

 Hyperlipidemia
 This is managed by her PCP. She is on simvastatin 20 mg. She is having bilateral leg pain over the past month. This could be related to the simvastatin possibly and given her age, it would not be unreasonable to stop the simvastatin, but I will defer to her PCP. She has no known CAD but if we were to do a TAVR evaluation and this was discovered, a statin would be indicated.

 Hypothyroidism
 She takes levothyroxine for supplementation and will continue this as is.

 Lightheadedness/dizziness
 She is on meclizine for this. It is possible that some of her lightheadedness and dizziness are related to the aortic stenosis, and we will do an echocardiogram as noted above. She is also having some PVCs on her EKG, which could be contributing, but she does not feel palpitations. We will consider a monitor but start with the echocardiogram first as noted above.


[doctor] hey kyle it's nice to see you today can you tell me a little bit about what brought you in [patient] yeah i went to see my pcp for a cough which they diagnosed as bronchitis but then they did that chest x-ray to make sure i did n't have pneumonia and they found this lung nodule i went for a cat scan that confirmed it and they referred me here to you i'm really nervous document [doctor] okay well first of all i'm i'm sorry that you're nervous and what we're gon na do is we're gon na partner together okay and i'm gon na be right by your side the whole time to hopefully make you a little less nervous and and recognize the fact that we're you're gon na have a big support team around you okay [patient] okay [doctor] so let's talk a little bit about how long you've had that cough before you went to see your doctor [patient] i you know off and on i've had it for about three months i first noticed it when i was loading some pay i have horses and i i bought you know four hundred bills a day and when i spent a day loading it and then it's i just started coughing a lot more i think around that time and after that i i i just got a cold so that's what sent me to my pcp now i i i do exercise i i do a lot of biking and i typically do n't get sick and my cough has gone away [doctor] okay that's good to hear you mentioned exercise and biking i love to bike myself i've got a track seventy one hundred hybrid have you been on the the new trails they opened it was the old the old rail the old rail road right away they've opened that up it's like sixty miles of trails [patient] i love that that road i just i i do n't like riding on the road so i prefer to do those rails the trails type [doctor] yeah [patient] and it's just so phenomenal i do that a lot [doctor] yeah i love riding over there way we will we will get you all fixed up we will have to go for a bike ride [patient] absolutely i'd love it [doctor] that'd be great so i see here on your medical history that you also have a history of rheumatoid arthritis is that under control at this time and and and what do you do to to take care of your ra [patient] yeah it's it's it's fair you know arthritis never really goes away but i take methotrexate [doctor] okay [patient] i think it's seven and a half milligrams every week and as long as i'm keeping active my joints feel okay and if i do have any problems it's it's mostly with my hands but i have n't had any recent flares so i'm okay right now [doctor] okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking [patient] i stopped smoking probably about seven years ago [doctor] okay [patient] and i was young and should have stopped the way before that my kids were on me all the time but you know i i got a new start and finally was able to stop and i felt better after stopping [doctor] okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that [patient] no not at all [doctor] okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies [patient] no lung cancer my mom did have breast cancer but she is doing well now [doctor] okay alright and then things like lung infections or pneumonia do you have any previous history of that [patient] no no not not anything that i'm aware of [doctor] okay if it's okay with you i'm gon na do a quick physical exam your vital signs look good today blood pressure of one twenty four over seventy six heart rate of seventy respiration rate of sixteen o2 sat on room air of ninety eight percent and you are afebrile so you do n't have a fever today i'm gon na take a quick listen to your lungs here your lungs are clear and equal bilateral when i listen to them or when i auscultate your lungs now listening to your heart regular rate and rhythm no clicks rubs or murmurs and i do n't appreciate any extra beats doing a quick extremity exam your skin is pink warm and dry i do n't appreciate any edema to your lower extremities it looks like you do have a little bit of swelling to to your knuckles there on your third digit on each hand which can be normal for somebody who has ra however pulses are intact in all extremities and capillary refill is brisk so a quick review of your results now you had a chest ct before you came in to see me and the results of that chest ct do show a solitary two centimeter nodule in the lateral aspect of the right upper lobe now it appears the nodule is smooth in appearance and no evidence of any type of emphysematous disease is present which is good now for my assessment and plan for you so you do have an incidentally found right upper lobe lung nodule i'm going to order some pft which is pulmonary function test i just wan na get a check and and a baseline for your lung function i'm also going to schedule a pet ct this is gon na help to determine if that nodule is metabolically active meaning if it lights up it it can suggest that it's cancer or inflammatory i'm going to go ahead and suggest that we do remove this during or via video assisted thoracoscopy which means it's just gon na be three small incisions made on the side of your right chest i'm gon na go in with a camera and a scope and we'll remove that along with a very small portion of your lung you're gon na be under general anesthesia and it'll take about an hour and a half or so post procedure you're gon na be admitted and you will have a chest tube in until the following day and i'm gon na go ahead and take that out then at bedside most likely you're gon na be in the hospital for one night and go home the next day it could be a benign nodule but because your smoking history i really do think it's gon na be best that you have that removed now for your secondary concern of your rheumatoid arthritis i want you to continue to follow up with your rheumatologist and continue your medication therapy as has been previously outlined for you now do you have any questions comments or concerns before before we get the paperwork signed to start the the treatment process [patient] no i do n't think so i think i'll be okay i'm scared [doctor] i i know you're scared but we'll be right here with you the whole way [patient] okay [doctor] alright we'll get some paperwork and i'll see you again in a few minutes [patient] okay thank you

ASSESSMENT AND PLAN

1. Right upper lobe lung nodule.
 - Medical Reasoning: The patient has incidentally found right upper lobe lung nodule visible on his chest CT. It could be a benign nodule, but because of his smoking history, I think it is best that he has it surgically removed.
 - Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. Surgery will require general anesthesia and will take approximately 1.5 hours. I explained to the patient that his procedure will consist of 3 small incisions being made on the side of his right chest. I will then insert a camera and scope to assist in removing the nodule along with a very small portion of his lung. He was advised that he will be admitted for most likely an overnight stay. He will have a chest tube in until the following day when I remove it at his bedside. All questions were answered.
 - Medical Treatment: Pulmonary function test ordered today to obtain patient's baseline. PET CT will also be scheduled to determine if the nodule is metabolically active, which can suggest if it is cancerous or inflammatory. Nodule will be removed via video assisted thoracoscopy.

 2. Rheumatoid arthritis.
 - Medical Reasoning: Stable.
 - Patient Education and Counseling: I encouraged the patient to continue to follow up with his rheumatologist.
 - Medical Treatment: Continue medication therapy and routine follow up with rheumatologist as previously outlined.


[doctor] hi , albert . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , albert is a 62-year-old male , with a past medical history significant for depression , type 2 diabetes , and kidney transplant , who is here today for emergency room follow-up . [patient] mm-hmm . [doctor] so , i got a notification that you were in the emergency room , but , but what were you there for ? [patient] well , i , uh , i was n't really , uh , staying on top of my , uh , blood sugar readings , and i felt kinda woozy over the weekend . and i was little concerned , and my wife wanted to take me in and just have me checked out . [doctor] okay . and , and was it , in fact , high ? [patient] yeah , it was . [doctor] okay . did you ... were you admitted to the hospital ? [patient] uh , no . [doctor] okay . all right . and , uh , are you ... did they see a reason , as to why it was elevated ? [patient] uh , yeah . my mother was actually in the hospital the last week. she had a bit of a fall and had to do a hip replacement. she's feeling better now but we have been just grabbing meals at the cafeteria or picking up fast food on our way home and i just really was n't monitoring what i was eating . [doctor] okay . that's sorry to hear . and are you feeling better now ? [patient] uh , actually , when we got home from the , uh , f- from the visit , i felt a lot better . [doctor] okay . and since then , have you been following your diet pretty closely ? [patient] yes . [doctor] okay . 'cause we do n't wan na end up in the hospitaltoo [patient] no . [doctor] all right . um , okay . and , so , before that happened , how are you doing with your diet ? [patient] uh , during the week , i've been fine , 'cause i've been very busy . on the weekends , doing things . you're seeing people . you're having people over . it's , i- not , not as consistent on the weekend . [doctor] okay . all right . um , is there a way that you think that that can improve ? [patient] uh , s- stop eating . [doctor] okay . all right . well , let's talk about your , your kidney transplant . how are- [patient] mm-hmm . [doctor] . you doing ? you're taking immunotherapy meds ? [patient] yes . [doctor] okay . [patient] yeah . i've , i've been pretty diligent about it , following doctor's orders , so it's been , it's been pretty good so far . [doctor] okay . and , and y- the last time i saw that you saw dr. reyes , was about three weeks ago , and everything seemed to be fine . [patient] that's correct . [doctor] your kidney function is good . [patient] yes . [doctor] okay . all right . and in terms of your depression , how are you , how are you doing ? [patient] and it's been about a , a tough , ugh , year-and-a-half or so , but i've been pretty good with it . i , i have my moments , but i- as long as i find some time to relax , at least in the afternoon , then , then it seems to work out okay . [doctor] okay . so , i know that we've kind of talked about holding off on medical therapy- [patient] mm-hmm . [doctor] . 'cause you're on so many other meds . [patient] mm-hmm . [doctor] um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ? [patient] uh , i think i probably wan na shy away from any therapy . my , my wife got me into meditation recently and , and , uh , i , i find that relaxing . so , i think i'd like to continue that , at least for a couple more months and see how it goes . [doctor] okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you- [patient] mm-hmm . [doctor] . checked in . do you have any symptoms , any chest pain or shortness of breath ? [patient] none whatsoever . [doctor] lightheadedness ? dizziness ? [patient] no . [doctor] no ? okay . um , and i just wan na go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey , dragon . show me the vital signs . [doctor] so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be . [patient] mm-hmm . [doctor] so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ? [patient] sure . [doctor] okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past . [patient] mm-hmm . [doctor] your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ? [patient] mm-hmm . [doctor] um , so , let's go ahead . i wan na look at some of your results . okay ? [patient] sure . [doctor] hey , dragon . show me the glucose . [doctor] so , right now , your blood sugar is about 162 . have you eaten before you came in here ? [patient] i did not . [doctor] okay . all right . um , hey , dragon . show me the diabetes labs . [doctor] okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high . [patient] mm-hmm . [doctor] so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated . [patient] mm-hmm . [doctor] so , we'll talk about , you know , how to go ahead and , and fix that . okay ? [doctor] so , let me talk a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further . [patient] mm-hmm . [doctor] okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , dragon . order a hemoglobin a1c . [doctor] for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ? [patient] mm-hmm . [doctor] okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications . [patient] okay . [doctor] um , and then , he knows to reach out to me if he needs anything . okay ? [patient] you got it . [doctor] all right . well , the nurse will be in soon to check you out . okay ? [patient] perfect . [doctor] hey , dragon . finalize the note .

ASSESSMENT AND PLAN

Albert Powell is a 62-year-old male with a past medical history significant for depression, type 2 diabetes, and kidney transplant. He is here today for an emergency room follow-up.

 Hyperglycemia.
 • Medical Reasoning: He was recently seen in the emergency department with elevated blood glucose levels. He admits to dietary indiscretion prior to this, but has since improved his diet. His recent blood glucose level was 162, and his recent hemoglobin A1c was 8.
 • Additional Testing: Repeat hemoglobin A1c in a few months.
 • Medical Treatment: Increase Lantus to 20 units at night.
 • Patient Education and Counseling: I advised him to continue monitoring his blood glucose levels at home and report those to me, as we may need to make further adjustments to his medication.

 Depression.
 • Medical Reasoning: He reports personal stressors over the past year and a half but is doing well overall. He recently started meditating.
 • Medical Treatment: He should continue his current management strategies. We will hold off on medication and therapy at this time.
 • Patient Education and Counseling: The patient was encouraged to contact me if he needs anything.

 Status post renal transplant.
 • Medical Reasoning: His kidney function appears stable and he has been compliant with his immunotherapy medications.
 • Medical Treatment: Continue seeing Dr. Reyes for management of his immunosuppression medication.
 • Patient Education and Counseling: He knows to reach out to me if he needs anything.


[doctor] hey charles i'm using this cool new recording device to help me with my documentation is that okay with you [patient] sure [doctor] awesome how are you doing today [patient] well i could be better you know i moved out in the city [doctor] about two years ago bought this big plot of land [patient] oh [doctor] i love it lots of deer round awesome [patient] you be hunter [doctor] huge hunter i love hunter yeah [patient] i have a refrigerator full of venison at home [doctor] do you [patient] mm-hmm [doctor] you want to carry share sure yeah we can switch [patient] nice but so the thing is i have noticed that for some reason my breathing [doctor] is n't what it used to be [patient] sure [doctor] yeah it's you know i i seem to catch my breath a lot more than i used to and i consider myself to be pretty healthy [patient] you look pretty healthy [doctor] thanks so do you thank you you you're feeling short of breath [patient] yes [doctor] okay is there you know is there any other symptoms that you have with that i get like you know mid shortness of breath suddenly for some reason i'm not quite sure why [patient] hmmm [doctor] eyes they're water does n't make very much sense to me [patient] mm-hmm [doctor] i always think it's allergies [patient] okay [doctor] mostly could be [patient] i have a dog that eyes water like that she always gets eyebugers [doctor] yeah i get eyebugers too [patient] uh [doctor] crazy uh the last time it happened i went to the urgent care and they gave me a nebulizer that helped [patient] they prescribed me an inhaler that i use now when i feel the symptoms coming on [doctor] okay great do you ever notice a rash with any of this [patient] no [doctor] do you have any nausea vomiting [patient] no [doctor] besides when you go out heavy drinking right [patient] i mean i diarrhea quite a bit once i go out [doctor] i understand that [patient] heavy drinking [doctor] yeah do you ever get lip or throat swelling [patient] no [doctor] have you ever had any issues with allergies in the past [patient] no [doctor] hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house [patient] i have noticed them in all three situations [doctor] hmmm [patient] in the house when the cat is n't around and outside as well [doctor] hmmm yeah i'm not a big cat person [patient] no neither [doctor] do you do you have any symptoms now well which is [patient] no [doctor] no no travels and no symptoms right now [patient] mm-hmm [doctor] okay [doctor] okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on your body there is no angioedema which is just swelling of your lips like you mentioned no audible stridor which is a bad noise in your airway when it gets swollen so that's good news if you just want to take a deep breath listening to your lungs on your lungs exam i do appreciate some faint expiratory wheezing bilaterally in all lung fields so i know you had a chest x-ray when you came in i'm looking at that chest x-ray right now and your pulmonary function test and they were both normal so let's talk a little bit about what i think is going on for your first problem you have newly diagnosed allergic asthma so i want you to continue the albuterol inhaler i do n't want you to wait until your symptoms flare up or are bad take it as soon as you start to feel any symptoms at all i'm gon na prescribe something else called singulair ten milligrams you might have seen some commercials for it [patient] hmmm [doctor] you take that once daily and that's gon na help decrease the occurrences of your asthma [patient] hmmm [doctor] i also am gon na proceed with allergy testing have you ever had an allergy test before [patient] no [doctor] okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next week to schedule the skin testing do you have any questions for me [patient] should i come my cats [doctor] yes

ASSESSMENT

Newly diagnosed allergic asthma.

PLAN

After reviewing the patient's examination, radiographic findings, and pulmonary function test results today, I have had a lengthy discussion with him regarding his current symptoms. He will continue to use the albuterol inhaler; however, he should limit its use to when he is experiencing a severe flare-up of symptoms. I advised he should take it as soon as he starts to feel any symptoms at all. I have also prescribed the patient Singulair 10 mg to be taken once daily. This should help to decrease the occurrences of his asthma. I have also recommended we proceed with an allergy skin test to target what his triggers are in the hope that we can avoid any other management. If we unable to determine his allergens, then we may consider further testing or immunotherapy.


[doctor] thanks , rachel . nice , nice to meet you . [patient] yeah . [doctor] um , as my nurse told you , we're using dax . so i'm just gon na tell dax a little bit about you . [patient] mm-hmm . [doctor] so rachel is a 48-year-old female here for shortness of breath . she has a history of depression , smoking , and chronic back pain . so tell me about this shortness of breath . [patient] okay . so there are times when i'm either doing very , very mild exercises or just walking , even if i'm just walking up , you know , my driveway , i find myself palpitating a lot , and there's a little bit of shortness of breath . [doctor] mm-hmm . [patient] i do n't know if it's got to do with the back pain , you know , whether that gets triggered as well at the same time . [doctor] right . [patient] but definitely i feel it happens more often lately . [doctor] okay . and anything else change recently ? like , have you changed lifestyle , like you're exercising more than you used to , having any allergies , anything like that ? [patient] probably exercising more to get rid of the covid 15 . [doctor] the covid 15 . yeah . now last time i saw you , you were smoking two packs a day . how much are you smoking now ? [patient] um , it's gone down quite a bit because , yeah , we said we have to make some , you know , changes as you get older . [doctor] yeah . [patient] so i would say it's probably , um , maybe , maybe a couple ... probably a coup- i do n't know . probably once or day or something . [doctor] just couple cigarettes a day ? [patient] probably once a day , yeah . [doctor] we're getting close . [patient] yeah . [doctor] that's awesome . [patient] mm-hmm . [doctor] that's great news . um , and then how's your depression doing ? [patient] i have my moments . [doctor] yeah . [patient] there are some days when i feel , you know , i wake up and everything was great . [doctor] uh- . [patient] and then there are times , i do n't , i do n't know whether it's got to do with the weather or what else kind of triggers it . [doctor] yeah . [patient] there are some days when i feel extremely low . [doctor] okay . and you had been taking the effexor for your depression . are you still taking that ? [patient] yes , i am . [doctor] okay , great . and then , um the chronic back pain , we've been giving you the gabapentin neurontin for that . is that helping control the pain ? [patient] i think it is . [doctor] yeah . [patient] it is ... it's definitely , um , i feel better . [doctor] uh- . [patient] but it does come every now and then . [doctor] right . what do you do when it's really bad ? [patient] um , i try to just get as much rest as i can . [doctor] okay . and you had talked about doing yoga . are you doing yoga anymore ? [patient] i wish i said yes , but i have n't really made it a habit . [doctor] okay . okay . well , um , you know , said ... you said you were coming in with shortness of breath , so we sent you to get some pulmonary function tests . [patient] mm-hmm . [doctor] so let's just look at those . hey , dragon , show me the pulmonary function tests . okay , so it looks like ... , it's interesting . it says that you might be having a little bit of asthma or , uh , copd . and if you are , we'll talk about that . [patient] mm-hmm . [doctor] let's look at our x-ray . hey , dragon , show me the most recent x-ray . okay , i said it wrong . hey , dragon , show me the most recent chest x-ray . okay , this is interesting . your ... kind of your diaphragm is a little bit flatter , and we'll see that in some , uh , copd , which happens with smokers often . so let's just do a quick physical exam . i know my nurse did the review of systems with you . is there anything else bothering you that we need to talk about today ? [patient] no other issues . [doctor] okay . great . let's do the exam . all right , so your physical exam looks pretty normal other than you've got kind of these mild wheezes in all your lung fields . and so i think you do have copd from your pulmonary function tests , your x-ray , and that . so i'm gon na diagnose you with copd . chronic obstructive pulmonary disease . it means you're not able to exhale appropriately . [patient] mm-hmm . [doctor] so we're gon na put you on a medicine called combivent . okay , you're gon na do two puffs twice a day . it's gon na help open up your lungs . it's an inhaler . [patient] mm-hmm . [doctor] i'm also gon na prescribe albuterol , which you use when you get really short of breath . it's like a rescue thing . [patient] mm-hmm . [doctor] um , and then i'm gon na prescribe some steroids to help , also some prednisone . so let me just order those . [patient] okay . [doctor] hey , dragon , order combivent , uh , two puffs twice a day . order albuterol , two puffs as needed . and order , uh , prednisone uh taper pack . okay , so and then it sounds like your depression's stable , so we're not gon na change anything . you're gon na keep taking the effexor . um , do yoga for depression and your back pain , so for your back pain , stay on the neurontin , and we just wo n't do anything different . any questions for me . [patient] no , i think this is good . thank you . [doctor] perfect . hey , dragon , finalize the note . why do n't you ...

ASSESSMENT AND PLAN

COPD.
 • Medical Reasoning: The patient presents today with shortness of breath with exertion. Her pulmonary function tests suggest asthma or COPD and her most recent chest x-ray and physical examination today are also consistent with COPD.
 • Patient Education and Counseling: I counseled the patient on the importance of smoking cessation.
 • Medical Treatment: We will start the patient on Combivent, 2 puffs twice a day. I will also prescribe an albuterol inhaler, 2 puffs as needed, and a prednisone taper pack.

 Depression.
 • Medical Reasoning: It sounds like her depression is stable, so we will not change anything at this time.
 • Patient Education and Counseling: She will keep taking the Effexor. I encouraged her to practice yoga for depression relief as well as her back pain.

 Chronic back pain.
 • Medical Reasoning: The patient says she is doing well on Neurontin with only occasional exacerbation of the pain.
 • Medical Treatment: She can continue Neurontin as is. I also encouraged her to practice yoga for her back pain.


[doctor] so barbara i i know you are here for some itchy scalp pain can you tell me a little bit about how you're doing [patient] yeah it's still quite a problem you know something i've been suffering with for so long now it's still quite itchy and it's really embarrassing too because i'll have dandruff so much like all over me but but i just ca n't stop itching [doctor] okay when did you first notice this [patient] i wan na say it's been a while but probably worsening in the past like six months or so [doctor] okay okay and have you seen ever noticed any rashes either when it first started or intermittently anywhere else [patient] on my body no not really [doctor] okay okay just mainly up underneath your on your scalp there uh and i can i can see that man that looks really itchy and scaly have you died your hair recently or used any other chemicals you you know like a new hair spray or gel [patient] nothing new i mean i do dye my hair but i've been doing that for years now but otherwise i do n't really use a lot of products in my hair [doctor] yeah i you know it's funny you say that because i keep saying i earned this gray hair and i'm gon na keep it so yeah have you tried any over the counter treatments i know there is a lot out of there something you know like a t gel or any of those other have those helped [patient] yeah i did that i did head and shoulders i even tried some castor oil and but none of them really seemed to be helping [doctor] okay okay let's talk about some other symptoms any joint pain fever weight loss [patient] not that i can recall i've been pretty good otherwise [doctor] okay good and going back you know to your grandparents has anybody else in the family had similar symptoms that you're aware of [patient] no well maybe my sister [doctor] maybe your sister okay [patient] yeah maybe my sister i mean i know she'll is no one has as bad as i do but she does report like just having a dry scalp [doctor] okay okay now you know a lot of times we can see this with you know high levels of stress has there been any new mental or emotional stressors at work or at home [patient] not really i mean it's basically the same things [doctor] okay yeah i yeah we have a lot of that yes so let me go ahead and and look at this a little closer here the first off i wan na tell you the the vital signs that the my assistant took when you came in your blood pressure is one thirty over sixty eight your heart rate was ninety eight and your respiratory rate was eighteen so those all look good and appear normal and your temperature was ninety seven . seven and that is all normal now when i look at your scalp here i do notice that you have demarcated scaly erythematous plaques and that's just kind of explaining technically what's going on those patches and they're they're in a patchy format they're diffusely present across the back of your skull and that's probably why you you see all that that that white dander you know on your on your your clothes as you go through the day now lem me talk a little bit about my impression and plan i think that you have a scalp psoriasis and let's and here is my thoughts on that what i would like you to use is to use clobetasol that's a zero . zero five percent solution and i want you to use that twice daily on the the affected areas of your scalp so you're just gon na put this on and just kinda gently rub it in now i know to do it twice daily is going to be difficult but if you can do it first thing in the morning when you get up and then before you go to bed you know get a shower and before you go to bed that will be great i want you to continue to use t-gel shampoo that you listed when you first came in that's a very good solution shampoo for that and that will help with controlling a lot of this now there is no cure for this unfortunately and flareups can be unpredictable but we see that you know not a we do n't have a great finger on what causes the flare ups but i'm gon na give you some steroids that will help and we're gon na have to manage that on a ongoing basis but when you get do get a flare up i want you to be using these flare steroid that i give you as we go through that and then i wan na see you back here in three months or sooner if it gets significantly worse do you have any questions for me [patient] no okay so i'll just use that steroid solution and then just as needed if it's really bad but then otherwise just use the t gel [doctor] yeah i want it's exactly what i want you to do i want you to use that that solution twice daily when you get that flare but then other than that just continue to use that t-gel shampoo [patient] alright [doctor] okay i'm gon na have my nurse come in and get you discharged but i the we will see you again in three months or and again please if it gets worse please do n't hesitate to call me and come in sooner [patient] alright perfect thank you [doctor] thank you [patient] okay bye

ASSESSMENT AND PLAN

1. Scalp psoriasis.
 - Medical Reasoning: The patient presents today with symptoms similar to scalp psoriasis.
 - Patient Education and Counseling: Nature of the diagnosis was discussed as well as treatment options. Patient was advised there is no cure for this. Patient was counseled on how to apply clobetasol 0.05%.
 - Medical Treatment: Prescription for clobetasol 0.05% solution twice daily provided. Continuing using T/Gel shampoo. Prescription for steroids provided to be used for flare ups.


[doctor] donna torres , date of birth , 08/01/1980 . [doctor] hi donna ! how are you ? [patient] i'm good . how about you ? [doctor] i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ? [patient] no , that's new . [doctor] okay . how is it working for you ? [patient] my anxiety is going good now , thankfully . i'm serious , it was brutal in november and december . finally , i was like ,  i can not do this .  i have no idea why it happened . dr. ward did put me on singulair , and she did say we need to be careful because singulair can cause anxiety . so i'm not sure if that was the issue or what . [doctor] mm . okay . [patient] and it would , um , start usually during the day , at work . [doctor] i see . [patient] i mean , i'm fine now . [doctor] well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too . [patient] i did . [doctor] and that was before we started the progesterone . [patient] yes . [doctor] so i know we started it for regulating your periods , but perhaps it helped with this also . [patient] yeah . and before , in november and december , i noticed that the week before my period , my anxiety would go through the roof . which then , i knew my period was coming . then it turned into my anxiety spiking just at random times . [doctor] hmm , okay . [patient] and it seemed like it was for no reason . [doctor] but november and december you were on the progesterone at that time . [patient] yes . [doctor] all right . so not really a link there , all right . [patient] yeah , i do n't know . [doctor] yeah , i do n't know either . um , sometimes with the aging process , that can happen too . [patient] i figured maybe that's what it was . [doctor] and we did go through the golive in november and december , so that can be pretty stressful also . [patient] yeah , and at work , that's when i first started to lead the process of delivering the results to patients with covid . in the beginning of the whole pandemic , patients would have to wait nine days before they'd get their results . and then we opened the evaluation centers and the covid clinic . so i think it just took a toll on me . [doctor] yeah , i can absolutely see that . [patient] yeah , and then i was feeling selfish because i was n't even on the front lines . i mean , i was supporting people , sure , but i was n't in the icu . so i felt selfish and guilty . i mean , hands down , the physicians and nurses were in the thick of it and there i was , having anxiety . and it felt ridiculous . [doctor] well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ? [patient] no . [doctor] have you lost weight ? [patient] no , but i stopped taking the camila birth control . my hunger level was at a new high . i mean , i was eating constantly . i felt like ,  what is going on ?  [doctor] all right . [patient] and now i am feeling better . [doctor] okay , that's good . and your masked face , though , it does look thinner . [patient] well , the past six months i have lost some weight . [doctor] okay , good . um , anything else going on ? [patient] no . [doctor] all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ? [patient] not with you , but i did around 2009 , and then i had to be seen every six months for a while . and then i had a normal pap . [doctor] all right , well , let's just repeat it then . [patient] yeah , that's fine with me , to be safe . [doctor] okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check . [patient] okay . i fight the vaccine fight every day at home because my husband is n't ready to get it . same with my daughter . she shares the same worries as her dad in how it'll impact her when she gets older . [doctor] have you had the vaccine ? [patient] yes , i have . and so has my son . he , um , has had his first already . [doctor] okay . well , you know , you can only do what you can do . [patient] yeah , i agree . [doctor] all right . well , let's complete your exam . [patient] all right . [doctor] so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps . [patient] yeah , but they're not as big as they were . [doctor] mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ? [patient] it does , where your left hand just was . [doctor] okay , right here ? [patient] yeah , down here . but whenever i breastfed , it was always sore there too . i had a clog and something else . the lumps do feel smaller , but they are still there , unfortunately . [doctor] yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away . [patient] yeah . [doctor] all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ? [patient] yes , and i actually need to get that refilled for the first time ever . [doctor] okay . [patient] uh , but yeah , i use it once a week and it does help . [doctor] okay , great . all right , looks good . [patient] good . [doctor] you can go ahead and sit up . [patient] thank you . [doctor] all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now . [patient] okay . and what could that mean ? [doctor] well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign . [patient] and i'm- i'm just worried because i'm almost 40 and my mom was almost 45 when she was diagnosed with breast cancer . so i mean , i know there's nothing i can do about it , but it's just i feel like , uh , we had it under control and now it is n't . [doctor] well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed . [patient] yeah . [doctor] so those are all good things . [patient] okay . [doctor] because , um , if it was cancer , we'd actually , we would see some change . [patient] we would ? okay , thank you for explaining that . [doctor] yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them . [patient] yeah , i agree there . [doctor] um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it . [patient] okay . i'll do whatever you think i should . [doctor] all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule . [patient] okay , i think that sounds great . [doctor] all right . i do too . all right , well any questions or anything else we can discuss today ? [patient] no , i think i'm all set . [doctor] all right , good . all right , well have a good rest of your day and just give us a call if you need anything else . [patient] all right , thank you . you have a good day too . [doctor] all right .

ASSESSMENT

• Follow-up bilateral breast cysts.
 • Pap smear.

PLAN

Follow-up bilateral breast cysts
 Physical exam indicated stable breast density bilaterally. The patient is being seen regularly for monitoring. The plan is to continue close monitoring and the patient will be referred to breast specialist for additional review. The patient agreed to this plan.

 Pap smear
 Exam was normal. No additional treatment needed at this time.


[doctor] hello . [patient_guest] hi . [doctor] i'm dr. evelyn , one of the kidney doctors . it's good to meet you guys . [patient_guest] it's nice to meet you also . [doctor] yeah . so i was reading about this syndrome that i actually have never heard of . [patient_guest] yeah , me too . [doctor] i do n't think it's very common . [patient_guest] definitely not . it's c- pretty rare . [doctor] so- [doctor] can you start at the beginning ? i know she's a twin , so are these your first two babies ? [patient_guest] no , i have a son also who is nine . he also has autism . [doctor] okay . [patient_guest] and when the twins were born , katherine , she was about 4 pounds , 8 ounces . and her twin was a bit smaller , at 3 pounds , 13 ounces . [patient_guest] katherine , she was doing fine . she just had problems with eating , where she would stop breathing when she was eating . [doctor] like preemie type stuff ? [patient_guest] uh- . yeah . she just had a hard time regulating her temperature , but she did fine . she does have a gi doctor , because she has reflex really bad . she also had a dietician , who told us to take her off cow's milk . which we did . and then she has seen an allergist , and also a neurologist ... who diagnosed her with this syndrome , because she still does n't walk and she was n't sitting by herself a year old . [doctor] yeah . [patient_guest] but so now she is crawling and she is trying to take steps , so think she's doing pretty good . [doctor] good . is she in therapy ? [patient_guest] she is in therapy . she's in feeding therapy , occupational therapy , and also physical therapy . [doctor] awesome . okay . [patient_guest] and we also have speech therapy , who is going to be starting within the next couple of weeks . [doctor] that's great . [patient_guest] so , she has a lot of therapies . we have also seen an orthopedic and an ophthalmologist . i can never say that . we have seen everything , really . [doctor] and audiology too , right ? [patient_guest] yes . [doctor] yeah , wow. . [patient_guest] yeah , it has definitely been a whirlwind of stuff . when we saw the geneticist , she told us that sometimes people with this syndrome , they have trouble with their kidneys . that they might actually fuse into one . she also said sometimes they have problems with their legs , so that was why we saw ortho . [doctor] okay . okay . [patient_guest] so we have seen everybody , really . we are just here to make sure that her kidneys are looking good right now . [doctor] yeah , okay . so , um , tell me about how many wet diapers she has in a 24 hour period ? [patient_guest] she has a lot . [doctor] so like normal 8 to 10 , or like 20 ? [patient_guest] yeah , it's around 8 to 10 . [doctor] okay . great . [patient_guest] yeah , she seems to pee a lot , and it feels like she drinks a lot too . [doctor] that's perfect . [patient_guest] and she used to only drink milk , and then i took her off dairy milk . so when i say milk , i actually mean , you know , ripple pea protein milk . [doctor] sure , yeah . [patient_guest] so i give her that milk , water now that she's used to it , and sometimes water with just a little bit of juice . so i do feel like she's drinking a lot better now . [doctor] that's great . and she's how old now ? [patient_guest] she'll be two mo- two next month . [doctor] okay . is her twin a boy or a girl ? [patient_guest] she's a girl . [doctor] okay , and how's she doing ? [patient_guest] she's doing really good . she's running around , and she does n't have any problems . [doctor] all right . is she bigger than her or the same size ? [patient_guest] they're about the same size . they're able to wear the same clothes , so ... [doctor] okay . [patient_guest] i do n't even think she's a pound hav- heavier , actually . [doctor] yeah . yeah . [patient_guest] but she is a little bit taller than her ... um , katherine . she's just sh- a little shorter and chunkier , but i think that's a part of her syndrome . [doctor] yeah . yeah , i was reading all the things associated with the syndrome . it sounds like we're looking for continual- congenital anomalies wi- of the kidney and urinary tract . which is basically something is wrong with the plumbing . [patient_guest] okay . [doctor] so the only way to know that , is to do a kidney ultrasound . [patient_guest] okay , that sounds okay . [doctor] okay . let me put that into the system , and then downstairs they can do the ultrasound . [patient_guest] all right , thank you . [doctor] okay , yeah . where do you all live ? [patient_guest] uh , we live in dallas . [doctor] okay . anybody in the family with kidney failure , dialysis or transplant ? [patient_guest] no . [doctor] okay . so let's get your ultrasound done , and we'll see how it goes . [patient_guest] all right , that sounds good . [doctor] all right . let me take a quick look at her . [patient_guest] sure . [doctor] all right . please use my physical exam template . um , i wan na take a quick listen to her heart and lungs . i'll look in her ears too . and she can sit , she can just sit on your lap . [patient_guest] okay . [doctor] all right . that's it . [patient_guest] all right , that was n't too bad . [doctor] hmm . so , let's complete the ultrasound today . i'll call you with the results . if it's normal , you wo n't need to see me again , but if it's abnormal , you can see me in kennesaw . [patient_guest] okay , that sounds good . [doctor] okay . we'll determine what the next steps are if there are any , after we see her results . [patient_guest] all right , sounds good . thank you . [doctor] you're welcome . the nurse will be in to have you complete some paperwork , and give you instructions for the ultrasound . we'll talk soon . [patient_guest] all right . thank you , and have a good day . [doctor] you too . [doctor] all right . physical exams show the well-nourished female , who is slightly fussy when examined . eyes are small appearing . she has mild hypotonia of the lower extremities in her arms . normal external female genitalia . [doctor] assessment and plan . katherine is a 22-month-old former 34 and 3-week-old , twin with smith magenis syndrome . several organ systems can be affected by this chromosomal deletion syndrome . congenital anomalies of the kidney and urinary tract have been reported in the literature . [doctor] we will obtain the screening of the kidneys by ultrasound today . if there are abnormalities on the kidney ultrasound , we will determine next steps and future follow-up . the family lives in dallas , georgia , so her follow-up should be at the town center location . [doctor] end of recording .

ASSESSMENT

• Smith-Magenis syndrome.
 Katherine is a 22-month-old former 34+3-week-old twin with Smith-Magenis syndrome.
 Several organ systems can be affected by this chromosomal deletion syndrome and congenital anomalies of the kidney and urinary tract have been reported in the literature.

PLAN

We will obtain a kidney ultrasound screening today. If there are abnormalities on the kidney ultrasound, we will determine the next steps and future follow-up. The family lives in Dallas, Georgia, so her follow-up should be at the Town Center location.


[doctor] kayla ward , date of birth , 4/28/07 . mrn 3-8-4-9-2-0 . she's here for a new visit with her mother for acne located on the face , which started about two years ago and is present most every day . she has been using persa-gel and washing regularly , which is somewhat helpful . there are no associated symptoms including itching , bleeding , or pain . no additional past medical history . she lives with her parents and sister . they have a dog , bird , and bunnies . she is in 7th grade . she plays basketball and volleyball and tap . she wears sunscreen in the summer , spf 30 . no additional family history . hi kayla , i'm dr. juan price . i hear you are starting to get some acne on the face . how about the chest and back ? [patient] it's not too bad . [doctor] so , it's not bad on the chest or back . you've used some over the counter items like washes and persa-gel ? [patient] yeah . [doctor] do those seem to be helping ? [patient] yes , i think so , a little bit . [doctor] good . what's your skin care routine like now ? [patient] do you wan na know , like , the things i currently use ? [doctor] yes . what do you do for your acne in the morning ? and then what do you do at nighttime ? [patient] i wash my face , more like i wipe it down in the morning . then at night i use an elf facial cleanser called the super clarity cleanser . i finish with a toner and then the persa-gel . [doctor] when you say ,  wipe your face in the morning ,  do you use a product or just water ? [patient] mm , just water and a washcloth , really . if i feel really greasy , sometimes i'll use the elf cleanser in the morning , too . [doctor] okay . and is today a good day , bad day , or an average day for you ? [patient] mm , i would say it's probably a good day for me , of course , since i'm here , right ? [doctor] acne is always good when you come to see the doctor . do you find that your acne flares with your periods ? [patient] no , not really . [doctor] and do you get a regular period ? [patient] yup . [doctor] how long have you been getting a regular period ? [patient] mm , i think about two years . [doctor] okay . [patient_guest] the biggest flare , probably , was when she started school sports in the fall , just with all the sweating . [doctor] yup , that will do it . is there anything else that you've noticed , mrs. ward ? [patient_guest] no . kayla really has been doing a good job with the facial care regimen . it just does n't seem to help as much as we wanted . [doctor] got it . okay . well , let's take a look then . full exam is performed today , except for under the underwear and under the bra . multiple benign nevi on the trunk and extremities . scattered skin colored papules . open and closed comedones . and erythmateous papules on the face , primarily on the forehead and with also some on the central cheeks and chin . the chest and back are relatively spared . and the remainder of the examination is normal . so , what i'm seeing from your exam today is mild to moderate acne , mostly comodonal with small inflammatory component . [patient] okay , so is there anything we can do to help it ? [doctor] yes . i would like to start with a topical therapy first . every morning , you will wash your face with a mild cleanser then use a moisturizer labeled ,  noncomedogenic ,  with sunscreen spf 30 or higher . this means it wo n't clog your pores . now , in the evening , wash your face with the same cleanser and allow it to dry . apply adapalene , 0.1 % cream , in a thin layer to the areas you generally get acne . i want you to start off using this a few nights a week and slowly work up to using it every night . if it is ... excuse me , if it is very expensive or not covered by insurance , you can try different gel over the counter . you can follow that with clean and clear persa-gel in a thin layer , or where you generally get acne . and then a noncomedogenic moisturizer . you're atopic retinoid will cause some sensitivity , so you will need to wear sunscreen when you are outside . it may also cause some dryness or irritation . [patient] okay , i can do that . [doctor] you also have multiple benign moles on your arms , legs , back and abdomen . this means they all look normal with no worrisome features . we will see if you have any progress over the next six months and follow up at that time . [patient] okay , that sounds good . thank you . [doctor] do you have any questions for me ? [patient] no , i do n't think so . [doctor] okay . if you have questions or concerns before your next visit , please call the office . [patient] thank you , doctor , we will .

ASSESSMENT

• Comedonal acne.
 • Multiple benign melanocytic nevi of upper and lower extremities and trunk.

 Kayla Ward is a 15-year-old female seen today for new acne evaluation. Full skin examination revealed mild to moderate comedonal acne with a small inflammatory component and multiple benign melanocytic nevi of upper and lower extremities and trunk.

PLAN

Comedonal acne.
 We discussed the diagnosis, etiology, and treatment options. I recommend starting with topical therapy first. The patient was instructed to wash face every morning with a mild cleanser, then use a non-comedogenic moisturizer with sunscreen SPF 30 of higher. In the evening, wash face with same mild cleanser and allow to dry. Apply a thin layer of topical retinoid, Retin-A 0.1% gel, to acne prone areas. Start off using a few nights a week, slowly work up to using every night. If it is very expensive or not covered by insurance, you can try Differin gel over the counter. Your topical retinoid will cause sun sensitivity, so you will need to wear sunscreen when you are outside. It may also cause some dryness or irritation.

 Multiple benign melanocytic nevi of upper and lower extremities and trunk.
 Reassurance given moles are normal in appearance and have no concerning characteristics. Will continue to monitor for progression or changes in 6 months.


[doctor] hi , roger . how are you ? [patient] hey . good to see you . [doctor] good to see you . are you ready to get started ? [patient] yes , i am . [doctor] roger is a 62 year old male here for emergency room follow-up for some chest pain . so , roger , i heard you went to the er for some chest discomfort . [patient] yeah . we were doing a bunch of yard work and it was really hot over the weekend and i was short of breath and i felt a little chest pain for probably about an hour or so . so , i got a little nervous about that . [doctor] okay . and had you ever had that before ? [patient] no , i never have , actually . [doctor] okay . and- [patient] whose mic is on ? i'm in . [doctor] okay . and , um , how are you feeling since then ? [patient] um , after , uh , we were done , i felt fine ever since , but i thought it was worth looking into . [doctor] okay . and no other symptoms since then ? [patient] no . [doctor] okay . and any family history of any heart disease ? [patient] uh , no , actually . not , not on my , uh , uh , on my immediate family , but i have on my cousin's side of the family . [doctor] okay . all right . all right . and , um , you know , i know that you had had the , uh , knee surgery- [patient] mm-hmm . [doctor] a couple months ago . you've been feeling well since then ? [patient] yeah . no problem in , uh , rehab and recovery . [doctor] okay . and no chest pain while you were , you know , doing exercises in pt for your knee ? [patient] no . that's why last week's episode was so surprising . [doctor] okay . all right . and in terms of your high blood pressure , do you know when you had the chest pain if your blood pressure was very high ? did they say anything in the emergency room ? [patient] um , they were a little concerned about it , but , uh , they kept me there for a few hours and it seemed to regulate after effect . so , it , it did n't seem to be a problem when i , when i went home . [doctor] okay . and , and i see here that it was about 180 over 95 when you went into the emergency room . has it been running that high ? [patient] uh , usually no . that's why it was so surprising . [doctor] okay . all right . all right . well , let's go ahead and we'll do a quick physical exam . so , looking at you , you know , i'm feeling your neck . i do feel a little enlarged thyroid here that's not tender . you have a carotid bruit on the right hand side and , uh , your lungs are clear . your heart is in a regular rate and rhythm , but i do hear a three out of six systolic ejection murmur . your abdomen is nice and soft . uh , there is the healed scar on your right knee from your prior knee surgery , and there's no lower extremity edema . [doctor] so , let's look at some of your results , okay ? [patient] mm-hmm . [doctor] hey , dragon , show me the blood pressure . yeah . and here , your blood pressure's still high , so we'll have to talk about that . um , hey , dragon , show me the ekg . so , here you- that's good , your , your ekg- [patient] mm-hmm . [doctor] . here is normal , so that's , that's very encouraging . um , i know that they had the echocardiogram , so let's look at that . hey , dragon , show me the echocardiogram . okay . so , looking at this , you know , you do have a little bit of a , a low pumping function of your heart , which , you , you know , can happen and we'll have to look into that , okay ? [patient] mm-hmm . [doctor] so , you know , my impression is is that you have this episode of chest pain , um , that could be related to severe hypertension or it could be related to some heart disease . so , what i'd like to go ahead and do is , number one , we'll put you on , um ... we'll change your blood pressure regimen . we'll put you on carvedilol , 25 milligrams twice a day . that helps with coronary disease as well as your pumping function of your heart . um , i wan na go ahead and order a cardiac catheterization on you and make sure that we do n't have any blockages in your heart arteries responsible for the chest pain . [doctor] for the high blood pressure , we're gon na add the carvedilol and i want you to continue your lisinopril 10 milligrams a day and i wan na see , uh , how your blood pressure does on that regimen , okay ? [patient] okay . sounds good . [doctor] all right . so , the nurse will be in soon and i'll ... we'll schedule that cath for you , okay ? [patient] you got it . [doctor] hey , dragon , finalize the note .

ASSESSMENT AND PLAN

The patient is a 62-year-old male who presents for emergency room follow-up. He presented to the emergency room for chest pain and elevated blood pressure of 180/95. His EKG from the emergency room was normal, but ejection fraction on echocardiogram was abnormal. His blood pressure today was still elevated.

 Chest pain and hypertension.
 • Medical Reasoning: Given his recent episode of blood pressure elevation and chest pain, I suspect an element of coronary artery disease as well as pumping dysfunction.
 • Medical Treatment: We will change his blood pressure regimen to carvedilol 25 mg twice a day. He should also continue lisinopril 10 mg a day and I want to see how his blood pressure does on that regimen. I also recommended cardiac catheterization on him to make sure that he does not have any blockages in his heart.


[doctor] hi logan . how are you ? [patient] hey , good to see you . [doctor] it's good to see you as well . [doctor] so i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain . [patient] mm-hmm . [doctor] so logan , what happened to your back ? [patient] uh , we were helping my daughter with some heavy equipment and lifted some boxes a little too quickly , and they were a little too heavy . [doctor] okay ... and did you strain your back , did something- [patient] i thought i heard a pop when i moved and i had to lie down for about an hour before it actually relieved the pain . and then it's been a little stiff ever since . and this was- what , so today's tuesday . this was saturday morning . [doctor] okay , all right . [doctor] and is it your lower back , your upper back ? [patient] my lower back . [doctor] your lower back , okay . and what- what have you taken for the pain ? [patient] i took some tylenol , i took some ibuprofen , i used a little bit of icy heat on the spot but it really did n't seem to help . [doctor] okay . and um ... do you have any numbing or tingling in your legs ? [patient] uh ... i felt some tingling in my toes on my right foot until about sunday afternoon . and then that seemed to go away . [doctor] okay , and is there a position that you feel better in ? [patient] uh ... it's really tough to find a comfortable spot sleeping at night . i would- i tend to lie on my right side and that seemed to help a little bit ? [doctor] okay , all right . [doctor] well , um ... so how are you doing otherwise ? i know that , you know , we have some issues to talk- [patient] mm-hmm . [doctor] . about today . were you able to take any vacations over the summer ? [patient] um ... some long weekends , which was great . just kind of- trying to mix it up through the summer . so lots of three day weekends . [doctor] okay , well i'm glad to hear that . [doctor] um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ... [patient] yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar . [patient] and uh ... i-i think i need to go clean for a couple of weeks . but other than that , it was been- it's been pretty good eating . [doctor] okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ? [patient] i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , but it's been pretty good and-and under control for the most part . [doctor] okay , and you're you're taking your medication ? [patient] yes , i am . [doctor] okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ? [patient] uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . not great , but it's been okay . [doctor] okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain . [doctor] have you had any other symptoms , chest pain , nausea or vomiting- [patient] no . [doctor] . fever , chills ? [patient] no . no none whatsoever . [doctor] no . okay . all right , well let me go ahead , i want to do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon ? show me the blood pressure . [doctor] so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your- [patient] mm-hmm . [doctor] . blood pressure go up . let's look at the readings . [doctor] hey dragon ? show me the blood pressure readings . [doctor] yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well . [patient] mm-hmm . [doctor] okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ? [patient] sure . [doctor] and kick against my hands . [doctor] okay , good . all right . [doctor] okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur . [patient] mm-hmm . [doctor] on your heart exam . which you've had in the past . [patient] mm-hmm . [doctor] so that sounds stable to me . [doctor] on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? [patient] mm-hmm . [doctor] hey dragon ? show me the diabetes labs . [doctor] okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? [patient] sure . [doctor] hey dragon ? show me the back x-ray . [doctor] so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- [patient] mm-hmm . [doctor] . the history , okay ? [patient] mm-hmm . [doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . [doctor] so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . [patient] mm-hmm . [doctor] i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- [patient] mm-hmm . [doctor] . and see how you do , okay ? [patient] you got it . [doctor] for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ? [patient] mm-hmm . [doctor] hey dragon ? order a hemoglobin a1c . [doctor] so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day . [patient] mm-hmm . [doctor] does that sound okay ? i think we need to get it under better control . [patient] no that's fine . i agree . [doctor] hey dragon ? order lisinopril 20 mg daily . [doctor] and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ... [patient] mm-hmm . [doctor] i do n't think we need to do any- any further , you know , work up of that at this time , okay ? [patient] mm-hmm . [doctor] do you have any questions logan ? [patient] not at this point . [doctor] okay . all right . [doctor] so the nurse will come in to help you get checked out , okay ? [patient] you got it . [doctor] hey dragon ? finalize the note .

ASSESSMENT AND PLAN

Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with low back pain.

 Lumbar strain.
 • Medical Reasoning: He injured his lower back while moving heavy boxes. His recent x-ray was unremarkable.
 • Medical Treatment: Initiate meloxicam 15 mg once a day.
 • Specialist Referrals: Referral to physical therapy.
 • Patient Education and Counseling: He was encouraged to continue icing the area and avoid strenuous activity.

 Diabetes type 2.
 • Medical Reasoning: His recent hemoglobin A1c was elevated at 8. He does admit to some dietary indiscretion lately.
 • Additional Testing: Repeat hemoglobin A1c in 6 months.
 • Medical Treatment: Increase metformin to 1000 mg twice a day.

 Hypertension.
 • Medical Reasoning: His blood pressures have been slightly elevated based on home monitoring and in clinic today.
 • Medical Treatment: Increase lisinopril from 10 mg to 20 mg a day.

 Osteoarthritis.
 • Medical Reasoning: This is mostly well controlled.
 • Medical Treatment: Continue to monitor the knee. No further work up is needed at this time.