[doctor] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . [doctor] hello , how are you ? [patient] i'm good , thank you . [doctor] so tell me what brings you in today . [patient] recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic . [doctor] or how have you been feeling in general with this ? [patient] not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me . [doctor] okay . are there any other symptoms ? [patient] i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess . [doctor] sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ? [patient] yeah , i've been anemic since i was 13 years old . [doctor] right . so why do your doctors think you're anemic ? do you have a history of heavy periods ? [patient] well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly . [doctor] yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ? [patient] about five to six years ago . [doctor] and was it relatively a normal exam ? did you have any polyps ? [patient] no . they said they'd see me in 10 years . [doctor] well that's good news . [patient] yeah , i agree . [doctor] um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ? [patient] no . [doctor] all right . do you ever drink alcohol ? [patient] yeah , but only once or twice a year . [doctor] okay . are you taking any supplements such as iron or vitamin b12 ? [patient] i already started taking my iron pills which i have not taken in about a year . [doctor] all right . and what are you taking ? [patient] i'm taking 25 milligram tablets , twice daily . [doctor] okay , and that's the , the ferrous sulfate ? [patient] yeah , that's it . i take one in the morning and one in the evening . [doctor] okay . anything else ? [patient] yeah , i take vitamin b12 , just the over the counter stuff . [doctor] okay , very good . all right , well let's go ahead and take a look and see what's going on . [patient] sounds good . thank you . [doctor] of course . you'll hear me , uh , talk through your exam so that i get all the information documented . [patient] okay . [doctor] all right . so use my general physical exam template . i will start by listening to your heart and lungs . [patient] okay . [doctor] all right . next , i'd like you to lay back so i can examine your abdomen . [patient] okay . [doctor] is there any tenderness where i'm pressing ? [patient] no . [doctor] okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding . [patient] is that why they want me to have another upper endoscopy ? [doctor] actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why . [patient] lovely . [doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . [patient] okay . [doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . [patient] all right . [doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled . [patient] okay . [doctor] um , have you ever had any issue with sedation in the past ? [patient] no , i was just sleepy afterwards . [doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . [patient] okay . sounds like a plan . [doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . [patient] okay , that sounds great . [doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you . [patient] thank you . [doctor] you're welcome . have a great day , have a great day ms. cooper . [patient] you too . [doctor] all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .

ASSESSMENT

• Iron deficiency anemia

 Mrs. Cooper is a 65-year-old female who was diagnosed with iron deficiency anemia in 12/2019 and was unable to donate blood. Her follow-up blood work in 01/2020 revealed a low hemoglobin, stable hematocrit, and normal iron labs, although, ferritin was low. She has been taking ferrous sulfate 325 mg by mouth.

PLAN

I have asked her to continue each ferrous sulfate dose with vitamin C found in orange juice for the next 12 weeks then recheck CBC, iron ferritin, B-12, and folate. A referral was sent for her to see a hematologist. We will plan for EGD and colonoscopy to assess for potential sources of anemia or GI bleed. If this is inconclusive, capsule endoscopy can be considered.


[doctor] sophia brown . date of birth , 3/17/1946 . this is a new patient visit . she's here to establish care for a history of dcis . we'll go over the history with the patient . [doctor] hello , ms. brown . [patient] hi . yes , that's me . [doctor] wonderful . i'm doctor stewart . it's lovely to meet you . [patient] you as well . [doctor] so , you've come to see me today because you had a right breast lumpectomy last year . is that right ? [patient] yes . on january 20th , 2020 . [doctor] okay . and how have you been since then ? any problems or concerns ? [patient] no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since . [doctor] perfect . i want to back up and go over your history so i can make sure everything in your chart is correct and i do n't miss anything . so , i'll tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing . sound good ? [patient] sounds good . [doctor] great . so , i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram , or was it done because you felt a lump ? [patient] it was just a normal one you're supposed to get every so often . [doctor] i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters . [patient] yes , that sounds right . hard to remember now , though . [doctor] yep , definitely . [doctor] based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5th , 2019 . pathology results during that biopsy came back as grade two , er positive , pr positive , dcis , or ductal carcinoma in situ . [patient] yes . unfortunately . [doctor] i know . scary stuff . but you had a lumpectomy on january 20th , 2020 , which removed the eight millimeter tumor and margins were negative . the pathology confirmed dcis . looks like they also removed 5 lymph nodes , which , thankfully , were negative for malignancy . that's great ! [patient] yeah , i was definitely very relieved . [doctor] and your last mammogram was in january 2021 ? and that was normal . [patient] yes . [doctor] okay . so , i feel like i have a good grasp of what's been going on with you now . and you're here today to establish care with me so i can continue to follow you and make sure you're doing well , right ? [patient] yes . fingers crossed . [doctor] definitely . we'll keep a close eye on you and take good care of you . [patient] okay , sounds good . [doctor] i have a few more questions for you . when was your last colonoscopy ? [patient] i had one in 2018 and , if i remember correctly , i had one polyp and that was removed and it was n't cancerous . [doctor] okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular adenoma . okay . and when was your last menstrual period ? [patient] gosh . it was probably around 30 years ago . [doctor] okay . do you have children ? [patient] i do . i have five . [doctor] ah , big family then . that's nice . [patient] yes . and they're all having kids of their own now , so it's getting even bigger . [doctor] i bet . sounds like fun . [patient] it is . [doctor] did you have any other pregnancies that were miscarriages or terminations ? [patient] really , i did not . [doctor] okay . so for the record , that's g5 p5 . and now that you're post-menopausal , are you currently or have you ever been on hormone replacement therapy ? [patient] my primary care doctor gave me the option years ago but i decided against it . [doctor] okay . and on your review systems form , you indicated that you've not had any recent weight loss or gain , headaches , bone pain , urinary symptoms , or blood in the stools . but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those . [patient] okay . so i've seen doctors for all of those . they've said , excuse me , the back and knee pain are age-related . and the cholesterol is a fairly new diagnosis , but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication . [doctor] okay . and your primary care doctor is following you for that , right ? [patient] that's correct . [doctor] okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ? [patient] yes , and that's all . [doctor] okay . so for your medical history , it's high cholesterol and stage 0 er/pr positive invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ? [patient] i did have my tubes tied after my last baby , but that's all . [doctor] okay . and how about family history ? [patient] my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it . [doctor] all right . any family history of breast cancer ? [patient] none . [doctor] did any of your children have medical issues or siblings with medical problems ? [patient] i do not have any siblings and , thankfully , my children are all healthy . [doctor] wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ? [patient] no drugs . i do drink socially , but never more than that . and i used to smoke , but really , everybody did back then and i probably quit about 30 years ago . [doctor] excellent . i have that you're allergic to penicillin . any other allergies ? [patient] nope , just penicillin . [doctor] okay . i think that covers it . hop up here and let me take a look at you . [doctor] okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes . [doctor] in the result section , note that her ecog performance status today is zero . [doctor] do you have ... did you have radiation after the lumpectomy ? [patient] i did . we also talked about endocrine therapy , but i decided against that . [doctor] okay . so your exam looks good , no masses , just some skin changes from that radiation . now , let's go over the plan for you . [patient] okay , sounds good . [doctor] as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy . [doctor] so , based on all of that , we can just continue to observe you . [patient] okay . that sounds great . and when do i come back in to see you ? [doctor] in a year , but you should have another mammogram in april of 2022 before you come back to see me . [patient] okay , i can do that . [doctor] wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ? [patient] i do n't think so . [doctor] okay , great . my nurse will be in shortly to discharge you . take care ! [patient] you as well .

ASSESSMENT

Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast.
 The patient is status post lumpectomy with removal of 5 lymph nodes which were benign. She also underwent adjuvant radiation therapy but declined endocrine therapy. Today’s clinical examination shows no evidence of recurrent disease or other malignancy. She also had a negative mammogram in 01/2021.

PLAN

1. We will continue to observe the patient.
 2. She is due for a mammogram in 04/2022.
 3. She should follow up with me in 1 year after the mammogram."


[doctor] next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma . [doctor] mrs. jackson , it's good to meet you . [patient] likewise , wish it were under better circumstances . [doctor] yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ? [patient] yes , that's what the biopsy said . [doctor] okay and when did you first notice the spot ? [patient] my mom noticed it when i was visiting her last month . [doctor] i see . and so you went to the dermatologist on april 10th to get it checked out , right ? [patient] yes , i wanted to be extra cautious because skin cancer does run in my family . [doctor] well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ? [patient] my mom and her sister , i think they both had melanoma . [doctor] okay . do you have any other types of cancer in the family , like breast or ovarian ? [patient] my grandfather had pancreatic cancer . [doctor] okay , and was that your mom or dad's father ? [patient] mother's . [doctor] okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ? [patient] no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before . [doctor] good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ? [patient] yes , that's correct . [doctor] okay , and for social history can you tell me what you do for work ? [patient] i own an auto repair shop . [doctor] okay and have you ever been a smoker ? [patient] yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying . [doctor] i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ? [patient] i had gall bladder and appendix . [doctor] okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ? [patient] no , i've been feelin' great . [doctor] good . well let me take a look at your back here where they did the biopsy if you do n't mind . [patient] sure . [doctor] okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ? [patient] okay , that's fine . [doctor] all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam . [doctor] okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further . [patient] okay , i should n't worry too much then ? [doctor] no , i have a low suspicion that it will show anything . [patient] okay , good . [doctor] so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision . [patient] okay , that is fine with me , i ca n't see back there anyways . [doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else . [patient] yeah , she did say she wants to see me back . [doctor] good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight . [patient] yeah , she definitely went over that , um , several times with me . [doctor] good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ? [patient] um , no i ca n't think of any at this time . [doctor] okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you . [patient] thank you , nice to meet you as well . [doctor] please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border . [doctor] for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin . [doctor] primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance . [doctor] after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

ASSESSMENT AND PLAN

The patient presents today with newly diagnosed melanoma. The biopsy revealed an intermediate thickness melanoma. On examination today, there is a right inguinal lymph node with slightly atypical consistency. I recommended an ultrasound to rule out metastatic disease. If the ultrasound is normal, the patient is a candidate for a wide local excision with a 1-2 cm margin. Primary closure should be possible, but skin graft closure may be needed. The relationship between tumor histology and prognosis and treatment was carefully reviewed. The need for follow up according to the National Comprehensive Cancer Network (NCCN) guidelines was reviewed. We also reviewed the principles of sun avoidance, skin self-examination, and the ABCDE’s of mole surveillance. After discussing the procedure, risks, expected outcomes and possible complications, questions were answered, and the patient expressed understanding and did choose to proceed."


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

ASSESSMENT

• Chronic congestive heart failure with mixed presentation.
 • Preop examination.
 • Diabetes mellitus.
 • Colonoscopy

PLAN

Chronic congestive heart failure with mixed presentation.
 She had an exacerbation of CHF earlier in the spring. We switched her from furosemide to torsemide and symptomatically, she is doing a lot better. She is about 1.5 kg down in weight. Her breathing is nonlabored. We are going to repeat an EKG today. Otherwise, continue her current regimen. Labs were checked and creatinine is appropriate. Her magnesium is below the preferred 2 at 1.7, with some occurrence of bilateral leg cramping, therefore we will start her on magnesium supplement.

 Preop examination.
 She is going to be having a right knee replacement at the end of 06/2021. We will schedule a preop check the first week or two of June prior to the surgery. She will discontinue clopidogrel for one week prior to knee replacement surgery; we will provide a reminder to patient of this as well.

 Diabetes mellitus.
 A1c is 5.5 on last check, so there is no need for a further A1c today. She may need another one prior to her surgery next month.

 Colonoscopy.
 The patient is overdue for a colonoscopy, which we will try to have done at County Hospital in the next month, prior to a change in her insurance. This is just a screening colonoscopy that she is overdue for. No family history of colon cancer.

 The patient understands and agrees with the recommended medical treatment plan.


[doctor] hi , bryan . how are you ? [patient] i'm doing well . i'm a little sore . [doctor] yeah ? [patient] yeah . [doctor] all right , well , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] that's fine . [doctor] so bryan is a 55-year-old male with a past medical history significant for prior discectomy , who presents with back pain . so , bryan , what happened to your back ? [patient] you ... my wife made me push a , uh , refrigerator out through the other room , and when i was helping to move it , i felt something in my back on the lower right side . [doctor] okay , on the lower right side of this back ? [patient] yes . [doctor] okay . those wives , always making you do stuff . [patient] yes .  [doctor] and what day did this happen on ? how long ago ? [patient] uh , this was about five days ago . [doctor] five days ago . [patient] and , you know , i have that history of discectomy . [doctor] yeah . [patient] and i'm just worried that something happened . [doctor] okay . all right . and , and what have you taken for the pain ? [patient] um , i have , uh , been taking ibuprofen . uh , and i tried once tylenol and ibuprofen at the same time , and that gave me some relief . [doctor] okay . all right . and have you had any symptoms like pain in your legs or numbing or tingling ? [patient] um , no , nothing significant like that . [doctor] okay , just the pain in your back . [patient] just the pain in the back . it hurts to bend over . [doctor] okay , and any problems with your bladder or your bowels ? [patient] no , no . [doctor] i know the nurse said to review a symptom sheet when you checked in . [patient] mm-hmm . [doctor] and i know that you were endorsing the back pain . any other symptoms ? chest pain ? shortness of breath ? abdominal pain ? [patient] no . [doctor] nausea ? vomiting ? [patient] no other symptoms . [doctor] okay . all right . well , let's go ahead and do a quick physical exam . hey , dragon , show me the vital signs . so your vital signs here in the office look really good . you do n't have a fever . your blood pressure's nice and controlled . so that ... that's good . i'm just gon na check out your back and your heart and your lungs , okay ? [patient] okay . [doctor] okay , so on physical examination , you know , your heart sounds great . there's ... it's a regular rate and rhythm . your lungs are nice and clear . on your back exam , you do have some pain to palpation of the right lumbar spine , uh , in the paraspinal muscles along with decreased flexion and extension of the back , and you have a positive straight leg on the right . or positive straight leg raise on the right , uh , but your strength is good bilaterally in your lower extremities . so that means that i think that you've injured your back . [patient] okay . [doctor] uh , but , you know , i think it's something that we can , we can fix , okay ? [patient] okay , you do n't think there's anything wrong with the ... where i had the surgery before . [doctor] i do n't think so . [patient] okay . [doctor] let's took at some of your results . hey , dragon , show me the back x-ray . so this is an x-ray of your lumbar spine . you know , there's good bony , bony alignment . i do n't see any fracture or anything like that . so that's a good sign . um , hey , dragon . show me the labs . and your labs here all look good , so i'm , i'm happy to see that . uh , so let's talk a little bit about my assessment and my plan for you , okay ? [patient] okay . [doctor] so i ... my assessment for your first problem , your back pain . i think you have a lumbar strain . i do n't think that anything else is going on , but i wan na go ahead and order an mri- [patient] okay . [doctor] just to be sure . [patient] okay . [doctor] okay ? and then i'm gon na prescribe you some meloxicam 15 milligrams once a day along with some ultram , 50 milligrams every four hours as needed , okay ? [patient] okay . [doctor] um , and then we'll go ahead and refer you to some physical therapy once we get the mri results back , okay ? [patient] should i continue to take the tylenol and the ibuprofen ? [doctor] you can stop the ibuprofen . [patient] okay . [doctor] you can take tylenol if you want . [patient] okay . [doctor] you know to call me if , if you need anything . [patient] okay . [doctor] okay ? [patient] okay . [doctor] any questions , uh , bryan ? [patient] no , no questions . [doctor] okay . hey , dragon , finalize the note .

ASSESSMENT AND PLAN

Bryan Smith is a 55-year-old male with a past medical history significant for prior discectomy, who presents with back pain.

 Lumbar strain.
 • Medical Reasoning: He reports right-sided low back after moving a refrigerator approximately 5 days ago. X-ray of his lumbar spine is unremarkable. I do not believe this is related to his previous discectomy.
 • Additional Testing: We will order a MRI of the lumbar spine for further evaluation.
 • Medical Treatment: Initiate meloxicam 15 mg once daily, as well as Ultram 50 mg every 4 hours as needed.
 • Specialist Referrals: We will refer him to physical therapy to be started after we get his MRI results back.
 • Patient Education and Counseling: I advised the patient to discontinue the use of ibuprofen, but he may continue using Tylenol if he wishes.


[doctor] good morning carolyn how are you [patient] i'm doing alright other than this ankle pain i've been having [doctor] so i see here that you hurt your right ankle can you tell me what happened [patient] yeah so yesterday i was going to take out the trash and it was quite icy i thought i was doing okay job and i just slipped and and fell and i'm pretty sure i heard a pop [doctor] okay and you said this happened yesterday correct [patient] yeah [doctor] okay and have you been able to walk on it at all [patient] no i was so initially when i first fell i was unable to walk at on it at all i had a friend that was visiting and so she heard me fall so she helped me inside now today i have been able to put a little bit more weight on it but i'm still limping [doctor] okay and then what have you been doing for your foot or ankle pain since that happened [patient] so i like iced it last night and kept it elevated and i also took some ibuprofen last night and this morning before coming in today [doctor] okay and can you rate your pain for me [patient] i would say right now it's like a four out of ten [doctor] okay and does the ibuprofen help with that pain [patient] it does it does help with the pain [doctor] okay and when you take your ibuprofen what can you what's your pain level then [patient] so this so what did i just say four [doctor] yes ma'am [patient] four out of ten so four out of ten is with ibuprofen [doctor] it's with ibuprofen okay what's your pain level without then [patient] i would say probably a six [doctor] okay [patient] i'm sorry it's a six out of ten without ibuprofen and it goes down to like a one with ibuprofen [doctor] okay alright that that sounds good have you ever injured that foot and ankle before [patient] you know i've had a lot of injuries to my ankle but i've never hurt this ankle before i just realized an error [doctor] okay you know and i see here that you have a history of playing sports looks like you played soccer in college and then played a little bit of a inner marrow soccer now [patient] yeah [doctor] i'm i'm guessing you probably have n't been able to do that since you hurt your ankle [patient] no i have not been [doctor] so did you hear about the new major league soccer stadium and team that's coming to town they opened in the this year actually they built the stadium have you been down there yet [patient] no i have to get there [doctor] yeah we are all excited it's going to be a good time well have you experienced any numbness or tingling in that right foot [patient] no [doctor] okay so if it's okay with you i would like to do a quick physical exam your vitals look good and everything there looks okay now i'm gon na do a focused exam on your right ankle i do appreciate some ecchymosis or bruising over the lateral malleolus malleolus associated with some edema or swelling of that area you are positive for tenderness to palpation of the anterior lateral soft tissue and now i do n't appreciate any laxity on anterior drawer and inversion stress there is no bony tenderness on palpation to that foot or ankle area now on neurovascular exam of your right foot you have brisk capillary refill of less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch and all of that is consistent with what's present on your left side as well so i did review the results of your of your x-ray the x-ray of your right ankle showed no fracture which is a good thing so now let me talk to you a little bit about my assessment and plan so for the first problem of right ankle pain your symptoms are consistent with a right ankle sprain or i'm sorry right ankle sprain of your lateral ligament complex more specifically your anterior talofibular ligament now this ligament's on the outside of your ankle ankle which got stretched when you fell the best treatment at this time for your sprain is to keep your leg elevated when you're seated and let's continue to ice okay you're gon na be given an air cast which is gon na help stabilize that ankle and i'm also going to prescribe some crutches because i want you to stay off that leg and start walking on it stay off your leg for now and then in a couple of days start walking on it as tolerated do you have any questions or concerns for me [patient] so how long do you think it'll take to heal [doctor] so your symptoms should significantly improve over a few weeks but i'd like to follow up with you and see how you're doing let's say i'll see you again in fourteen days now i do want you to go ahead and continue to take nsaids or ibuprofen as needed to help with any pain and that's also gon na help reduce that inflammation and swelling okay [patient] okay [doctor] alright i will see you again in two weeks carolyn [patient] great thank you [doctor] you're welcome

ASSESSMENT

Lateral ligament complex sprain, Right ankle.

PLAN

After reviewing the patient's examination and radiographic findings today, her symptoms are consistent with a right ankle sprain of the lateral ligament complex, more specifically the anterior talofibular ligament. We had a lengthy discussion regarding the nature of this injury and the course of treatment. I advised her to keep her leg elevated when she is seated and continue to ice her ankle. She should also continue taking ibuprofen as-needed for pain and inflammation management. She will be placed in an Aircast to help stabilize her ankle, and I am going to order crutches so she can remain non-weight-bearing for the next couple of days. At that point, she can start bearing weight on the ankle as tolerated.


[doctor] good morning ms. reyes ! [patient] good morning . [doctor] how are you doing ma'am ? [patient] i'm doing well doctor , how are you ? [doctor] i am fine thank you . so you've been having some problems with your right hip ? [patient] yeah . [doctor] okay , and where are you hurting ? can you show me ? [patient] right in the groin area . [doctor] okay , and this has been going on since february 2020 ? [patient] yeah . [doctor] okay . and is it worse with movement ? [patient] well when it catches and i almost fall , yeah . [doctor] okay . so it kinda grabs you ? [patient] yeah . [doctor] okay , and this all started when you were walking ? [patient] well , walking around the infusion room . [doctor] okay . [patient] so it started if i took a step back or , you know , stuff like that . now it happens anywhere . [doctor] okay , so now it hurts whenever you move ? [patient] it hurts when i pivot . [doctor] okay . so if you pivot then it hurts , got it . um ... [patient] anything can sometimes do it . sometimes it wo n't though , and sometimes it'll do it several times in a row . [doctor] several times in a row , okay . [patient] and sometimes i fall . [doctor] okay . and you rate the pain to range from two through seven out of 10 ? [patient] yeah , that's correct . [doctor] okay . and are you experiencing fever or chills ? [patient] no . [doctor] okay . and any tingling or numbness ? [patient] no . [doctor] and have you had any problems with your bowel or bladder ? [patient] no . [doctor] okay . and if you stay still , do you feel better ? [patient] yes , but i do n't want to stay still . [doctor] i understand , no problem . and for past medical history , do you have anything going on ? [patient] i've had a lot of surgeries . i've had pcl , i had infertility , a gall bladder removed , but that's it . [doctor] okay . and for family history , it looks like there's high blood pressure , diabetes , thyroid disease , heart disease , kidney disease and gastric ulcers . for your current medications , it does n't look like you're taking anything at this time . and you're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ? [patient] yes , i've lost 110 pounds . [doctor] that is awesome . and how did you do that ? [patient] with weight watchers . [doctor] that's great . [patient] mm-hmm . [doctor] and how many months have you been participating in weight watchers ? [patient] i started in 2018 , and i've been at my current weight for a little over a year . [doctor] that is awesome . [patient] yeah , thank you . [doctor] yeah , very good , and congratulations . and so , for social history , it looks like you work at an infusion center ? [patient] yes , over at . [doctor] okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month . [patient] that's correct . [doctor] all right . well let's go ahead and take a look at your hip . [patient] okay . [doctor] please use my general physical exam template . physical exam . ms. reyes is a pleasant 56-year-old woman who is five feet , six inches in height , weighing 169 pounds . blood pressure is 115 over 75 . pulse rate is 67 . ankles , no ankle edema is noted , no calf tenderness . okay , ms. reyes , can you go ahead and stand up for me please and take a couple of steps ? great . [patient] okay . [doctor] and can you walk on your tippy toes ? good , okay . and can you walk on your heels ? kind of a heel walk and toe walk are intact . um , go ahead and turn around please . [patient] okay . [doctor] examination of the cervical spine , any pain here now ? [patient] no . [doctor] okay , no tenderness . look at your right and your left and then over to the right , then go ahead and look up , then look down , and look straight ahead . range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ? [patient] no . [doctor] okay . skin is intact , no midline tenderness to palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ? [patient] no . [doctor] okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ? [patient] no . i did or do have several bulging discs . [doctor] okay . but you're not hurting right now ? [patient] no , the weight loss has really decreased all the pain . [doctor] okay . range of motion is decreased in exertion . lateral flection without pain . any pain when i push ? [patient] no . [doctor] okay . you can go ahead and , um , sit down please . no pain ? [patient] no . [doctor] okay . sacroiliac signs are negative . examination of the hips . trochanteric is non tender . go ahead and lift your knee up , does that bother you ? [patient] um , just a little bit . [doctor] okay , little bit . and then back one , probably bothers you ? [patient] right there , like there , yeah . [doctor] okay . how about this way ? not too bad ? [patient] no . [doctor] okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . okay , go ahead and keep it up , do n't let me push it down . does that hurt ? [patient] right there . [doctor] okay . resisted right hip flection causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ? [patient] yeah . [doctor] okay . motor control is normal in the lower extremities . go ahead and lift your knee up . [patient] okay . [doctor] okay , lift it up . any pain ? [patient] no . [doctor] okay . and this one ? [patient] yeah . [doctor] and squeeze your knees together , push it out and kick your leg out straight . now go ahead and bring it back and kick it out straight again . and go ahead and lean back , keep it loose . okay , all set . you can go ahead and sit up now . [patient] okay , thank you . [doctor] you're welcome . so what i think we're dealing with is right hip degenerative joint disease . [patient] okay . [doctor] and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort , as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain . [patient] hmm , i do n't love that idea but i'll give it a try . [doctor] okay , that would be great . and we can also try a cortisone injection into the right hip joint to see if that offers any relief . [patient] i would like to definitely get the injection . [doctor] okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed . [patient] okay , that sounds good . [doctor] okay . and here are the risks associated with getting the inje- injection . um , please just take a moment to review it and consent to the shot . [patient] i'm good . [doctor] great . we'll get that set up for ya . all right , well i hope things , um , feel better , and we will see you back here in three months . [patient] see you . have a nice day . [doctor] thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile and covid . she understood and decided to proceed with the injection . she will follow up with me in three months for another injection if needed . end of dictation .

ASSESSMENT

• Right hip degenerative joint disease.

PLAN

I discussed the clinical and radiological findings with the patient. Treatment options discussed are low impact exercises, use of analgesics as needed, and use of a cane to offload the right hip. She would like to proceed with a cortisone injection into her right hip joint. We will administer the injection today. I reviewed the procedure in detail, including the risks of the injection related to the use of steroid in the COVID setting. She understands the risks and would like to proceed with the injection.


[doctor] hello , mrs . martinez . good to see you today . [patient] hey , dr . gomez . [doctor] hey , dragon , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ? [patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm . [doctor] so you have pain in your distal radius ? [patient] yes . [doctor] how did that happen ? [patient] um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm . [doctor] okay . and did it swell up at all ? or- [patient] it did . it got a ... it had a little bit of swelling . not a lot . [doctor] okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ? [patient] a little bit when i move my wrist . um , no numbness in my hand . [doctor] okay . do you have any past medical history of anything ? [patient] um , yes . allergic , um , l- i have allergies . and so i take flonase . [doctor] okay . and any surgeries in the past ? [patient] yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work- [doctor] okay . [patient] on my rake . [doctor] okay . [patient] yeah . [doctor] i was wondering where you were going to go with that . [patient] yeah . [doctor] okay . great . so , let's take a look at , uh , the x-ray of your arm . hey dragon , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you . [patient] okay . [doctor] does it hurt when i press on your arm here ? [patient] yes . [doctor] okay . how about when i bend your arm ? [patient] yes . [doctor] okay . that's pretty tender , ? [patient] mm-hmm . [doctor] how about when i go backwards like that ? [patient] not as much . [doctor] and how about when i flex like this ? [patient] a little . [doctor] but mostly when i do that type of motion ? [patient] yes . [doctor] okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again . [patient] okay . [doctor] okay , great . hey dragon , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . dragon you can finalize the note . [patient] thank you .

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and anti-inflammatory medications. I am prescribing Motrin, 800 mg to take 3 times a day with food. She will follow up with me in 1 week or as needed.
 "


[doctor] hey matthew how're you doing [patient] hey doc i'm doing pretty good how are you [doctor] i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that [patient] yeah i did my wife and i were on a walk yesterday and i was just talking to her and and stepped off the curb and landed on it wrong it's kind of embarrassing but yeah it's been killing me for a couple days now [doctor] okay now when you fell did you feel or hear a pop or anything like that [patient] i would n't say i really heard a pop it was just kind of really kind of felt extended and stretched and it it's just been really bothering me ever since kind of on the outside of it [doctor] okay and then were you able to walk on it after the incident [patient] i was able to get back to the house because i did n't wan na you know make my wife carry me but it was it was painful [doctor] okay and then have you done any or had any injuries to that ankle before [patient] nothing substantial that i would say in the past [doctor] okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less [patient] i have taken some ibuprofen and then i just tried to elevate it and ice it a little bit and keep my weight off of it [doctor] okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me [patient] i would say it's about an eight [doctor] okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then [patient] maybe a seven it it's a little [doctor] okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there [patient] we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time [doctor] yeah i [patient] no i have n't been there yet [doctor] yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay [patient] awesome [doctor] so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up [patient] no i think that sounds like a plan [doctor] okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks [patient] awesome thanks document [doctor] alright thanks bye-bye

ASSESSMENT

Left ankle sprain of the lateral ligament complex.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his symptoms are consistent with an ankle sprain of the lateral ligament complex. The nature of the diagnosis and treatment options were discussed. At this time he will continue to follow the RICE protocol. He will continue to take NSAIDs as needed for pain and swelling. He will also be placed into an Aircast for ankle stabilization and will be provided crutches in order to remain non-weight-bearing. We discussed that it may be a few days before he feels able to tolerate walking. I also advised him that his symptoms will likely start to improve significantly over the next 4 to 6 days.


[doctor] hi , martha . how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ? [patient] i'm doing well . i've been traveling a lot recently since things have , have gotten a bit lighter . and i got my , my vaccine , so i feel safer about traveling . i've been doing a lot of hiking . uh , went to washington last weekend to hike in northern cascades, like around the mount baker area . [doctor] nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person . [patient] yes , fall foliage is the best . [doctor] yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ? [patient] i've been doing well with that . i resisted , as much , as i could , from the tater tots , you know , the soft pretzels , the salty foods that i , i love to eat . and i've been doing a really good job . [doctor] okay , all right . well , i'm glad to hear that . and you're taking your medication ? [patient] yes . [doctor] okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ? [patient] no , not that i've noticed . [doctor] okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or- [patient] yeah , it's been helping a lot . i've been going every week , um , for the past year since my last annual exam . and that's been really helpful for me . [doctor] okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ? [patient] no , nothing like that . [doctor] okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ? [patient] i'm still forgetting to take my blood pressure medication . and i've noticed when work gets more stressful , my blood pressure goes up . [doctor] okay . and , and so how has work going for you ? [patient] it's been okay . it's been a lot of long hours , late nights . a lot of , um , you know , fiscal year end data that i've been having to pull . so , a lot of responsibility , which is good . but with the responsibility comes the stress . [doctor] yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ? [patient] no , nothing like that . [doctor] no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] hey , dragon , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , dragon , show me the blood pressure readings . hey , dragon , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ? [patient] okay . [doctor] so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ? [patient] okay . [doctor] okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ? [patient] okay . [doctor] let's go ahead , i wan na look at some of your results , okay ? hey , dragon , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ? [doctor] um , hey , dragon , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ? [patient] okay . [doctor] um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ? [patient] okay . [doctor] i also wan na repeat another echocardiogram , okay ? [patient] all right . [doctor] hey , dragon , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently . [patient] no , i feel the same way . [doctor] okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ? [patient] okay . [doctor] do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ? [patient] okay . [doctor] okay . do you have any questions ? [patient] can i take all my pills at the same time ? [doctor] yeah . [patient] 'cause i've been trying to take them at different times of the day , 'cause i did n't know if it was bad to take them all at once or i should separate them . i do n't know . [doctor] yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm- [patient] okay . [doctor] . some time during the day to take them , okay ? [patient] that might help me remember better . [doctor] all right . that sounds good . all right , well , it's good to see you . [patient] good seeing you too . [doctor] hey , dragon , finalize the note .

ASSESSMENT AND PLAN

Martha Collins is a 50-year-old female with a past medical history significant for congestive heart failure, depression, and hypertension who presents for her annual exam.

 Congestive heart failure.
 • Medical Reasoning: She has been compliant with her medication and dietary modifications. Her previous year's echocardiogram demonstrated a reduced ejection fraction of 45%, as well as some mitral regurgitation. Her cholesterol levels were slightly elevated on her lipid panel from last year.
 • Additional Testing: We will order a repeat echocardiogram. We will also repeat a lipid panel this year.
 • Medical Treatment: She will continue with her current medications. We will increase her lisinopril to 40 mg daily and initiate Lasix 20 mg daily.
 • Patient Education and Counseling: I encouraged her to continue with dietary modifications.

 Depression.
 • Medical Reasoning: She is doing well with weekly therapy.

 Hypertension.
 • Medical Reasoning: She has been compliant with dietary modifications but has been inconsistent with the use of her medication. She attributes elevations in her blood pressure to increased stress.
 • Medical Treatment: We will increase her lisinopril to 40 mg daily as noted above.
 • Patient Education and Counseling: I encouraged the patient to take her lisinopril as directed. I advised her to monitor her blood pressures at home for the next week and report them to me.

 Healthcare maintenance.
 • Medical Reasoning: The patient is due for her routine mammogram.
 • Additional Testing: We will order a mammogram and have this scheduled for her.


[doctor] mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool app that i'm using that's gon na help me focus on you a bit more would that be alright with you [patient] yeah that sounds great [doctor] okay great so mark tell me about your right elbow pain what's been happening [patient] so yeah i've been playing a lot of tennis recently buddy of mine you know you're always telling me to get off the couch and be more active so a buddy of mine asked me if i wanted to go play tennis he just joined a country club i've been hitting hitting the cord a lot more and it's just been killing me for the last three weeks or so [doctor] okay alright and where in your elbow is it hurting [patient] outside part [doctor] hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else [patient] no it does n't [doctor] okay and what would you say the pain is you know on a scale of zero to ten [patient] it's probably an eight when i'm just when i'm using it even if it's to get something out of the cupboard and it's a three when i'm just kinda resting [doctor] hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it [patient] all of the above shooting stabbing very sharp [doctor] okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you [patient] not that i can recall [doctor] okay and and you said it's it's worse with movement better with rest is there anything else that makes it makes it worse or makes it better [patient] i've taken some tylenol and ibuprofen but as soon as those wear off it it comes right back so they do n't really help [doctor] okay [patient] and i did try a little ice i probably should ice it more but i did n't notice it helping much [doctor] okay okay alright yeah well i definitely i'm glad you're getting some exercise now that's good for your diabetes and all that and out there playing tennis kinda back back to the back to the old days for you right did do i recall that were n't you a big tennis player back in the day like state champ in high school or something [patient] yeah yeah that was a hundred years ago i ca n't i i try to play like that and i ca n't i ca n't do that anymore but yeah a good memory that's a that's a good memory [doctor] now [patient] kind of a tennis guy too right did you see the the australia open [doctor] i did i did yeah that was that was crazy that was a great tournament what a what a finish unbelievable [patient] yeah hey did you see the masters i know you're a golfer [doctor] yeah yeah yeah i do n't get out as often as i as as i like to but but the masters yeah that was that was amazing that was lot of fun to lot of fun did you catch it too [patient] i did [doctor] yeah [patient] yeah [doctor] yeah [patient] but that's it was i i could n't believe tiger went out there of course he did [doctor] right [patient] it was cool to see nothing [doctor] yep yep agreed agreed and so well listen we'll we'll hopefully get you feeling better here and get you back out on the court and out on the course and we'll talk about that but let's let me ask you about your diabetes a little bit a little bit here so how have your blood sugars been running mark have they been what in the low one hundreds two hundreds where are they [patient] they are like one fifty one sixty you know we just had easter and my kids got a whole bunch of candies so i keep eating that [doctor] hmmm okay yeah yeah understood so those cadboy eggs they'll get you every time too right [patient] yes [doctor] boy my gosh yeah those are the best so those are those are deadly do n't tell my cardiologist so okay so listen you know i see that we have you on metformin five hundred milligrams once a day no actually last visit we increased it so i've got you on metformin five hundred milligrams twice a day correct you're still taking that [patient] yes twice a day [doctor] okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed [patient] yeah knock on wood i my asthma is pretty much under control [doctor] okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct [patient] that's correct yes [doctor] okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct [patient] yes that's right [doctor] okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you [patient] kills [doctor] okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you [patient] yeah it hurts a little bit [doctor] okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joint effusion and otherwise it's a normal right elbow x-ray so that's reassuring okay and hey you know i meant to ask you you know and do you have any history of fever recently you know along with the elbow pain you had noticed a fever [patient] no i do n't think so [doctor] okay great excellent alright so tell you what let's let's talk about my assessment and your plan here so for your first problem my assessment is is that you have acute lateral epicondylitis of your right elbow and this is also known as tennis elbow go figure right so this is due to overuse likely the increase in your your tennis activity which normally would be good but maybe we're overdoing it a little bit so i have a few recommendations i'd like you to rest your right arm as much as you can i want you to stop tennis for the next four to six weeks and please avoid repetitive stress in that right arm as well i want you to ice that right elbow for twenty minutes at least three times per day and this should reduce the pain and inflammation and then i'm also going to give you a brace for your right forearm and my nurse will give this to you before you leave that should help with the discomfort okay in that right elbow i will also write you a prescription for ultram and this should help with the pain i'll write you a prescription ultram fifty milligrams once per day that should help with your elbow pain so then i wan na see you in follow-up in four weeks and so we'll reevaluate your elbow at that time and if you we'll consider some additional imaging if needed possibly a physical therapy referral depending on how you're doing mkay now for your second problem of diabetes type two my assessment is is that your blood sugar is a little bit out of control mkay so we need to make some adjustments i'm going to increase your metformin to one thousand milligrams twice per day and i want you to check your blood sugar twice daily for the next two weeks and then let me know how your blood sugar is running and we can make some additional adjustments if needed but i will increase your metformin to one thousand milligrams twice a day now i'm going to also order a hemoglobin a1c level and and a cbc blood test today and and so we'll check those results the hemoglobin a1c and the cbc and then i'm going to also check a chem-12 blood test as well and now for your third problem of the mild acute intermittent asthma you my assessment is that it really remains under good control so let's keep you on that flovent and the albuterol no changes there and you can use those as tolerated it does look like you need a refill on your albuterol so i'm gon na write you a prescription for a refill of the albuterol and you can pick that up at your pharmacy as well so how does that all sound any questions for me [patient] it sounds pretty good i ca n't believe it's just tennis elbow feel like a looser coming in here but it's okay i get it [doctor] yeah yeah well [patient] i'm not i'm not young anymore [doctor] yeah well let's let's keep you active but take a break for a bit and let's ease back into it okay so it's great to see you and i'll see you back in four weeks let me know if you have other problems in the meantime [patient] okay

ASSESSMENT AND PLAN

1. Acute lateral epicondylitis of right elbow.
 - Medical Reasoning: Patient presents today with symptoms consistent with lateral epicondylitis secondary to overuse.
 - Patient Education and Counseling: The nature of the diagnosis was discussed. He was advised that this is like due to increased tennis activity and was encouraged to rest as much as possible. - Medical Treatment: Patient will discontinue playing tennis for the next 4 to 6 weeks, as well as avoid repetitive stress with the right arm. He will apply ice to the elbow for at least 20 minutes 3 times per day to reduce pain and inflammation. Right forearm brace was provided today to help with discomfort. Prescription for Ultram 50 mg once per day was also provided for pain.

 2. Diabetes type 2.
 - Medical Reasoning: His blood sugar today is not controlled.
 - Patient Education and Counseling: We discussed that I would like him to take his blood sugars twice a day for the next 2 weeks and to let me know how they are running so we can make additional adjustments if needed.
 - Medical Treatment: He will increase his metformin to 1000 mg twice a day. He will begin home blood sugar monitoring twice a day for the next 2 weeks. Hemoglobin A1c, CBC, and a Chem-12 test were ordered today.

 3. Mild acute intermittent asthma.
 - Medical Reasoning: This remains well-controlled.
 - Medical Treatment: The patient will continue his Flovent twice a day. Refill of albuterol provided today to be used as needed.


[doctor] hi , joseph . how are you ? [patient] hey , i'm okay . good to see you . [doctor] good to see you . are you ready to get started ? [patient] yes , i am . [doctor] okay . joseph is a 59 year old male here for routine follow-up of his chronic problems . so , joseph , how have you been doing ? [patient] yeah , i've been kind of managing through my depression , and , uh , my asthma's been acting up 'cause we had a really bad pollen season , and i am at least keeping my diabetes under control , but just , uh , it's just persistent issues all around . [doctor] okay . all right . well , let's start with your diabetes . so , your diet's been good ? [patient] um , for the most part , but we have been traveling all over to different sports tournaments for the kids , so it was , uh , a weekend of , uh , eating on the go , crumby junk food , pizza , and did n't really stick to the diet , so that was a bit of an adjustment . [doctor] okay . all right . um , but , ha- ha- have you ... let's just talk about your review of systems . have you had any dizziness , lightheadedness , fever , chills ? [patient] running up and down the stairs , it was pretty warm , so i did feel a little bit lightheaded , and i did get a little dizzy , but i thought it was just the heat and the fatigue . [doctor] okay . any chest pain , shortness of breath , or belly pain ? [patient] shortness of breath . no belly pain though . [doctor] okay . all right . and , how about any joint pain or muscle aches ? [patient] uh , my knees hurt a little bit from running up and down , and maybe picking up the boxes , but nothing out of the ordinary . [doctor] okay . all right . um , and , in terms of your asthma , you just said that you were short of breath running up and down the stairs , so , um , do , how often have you been using your inhaler over the past year ? [patient] only when it seems to go over about 85 degrees out . that's when i really feel it , so that's when i've been using it . if it's a nice , cool , dry day , i really do n't use the inhaler . [doctor] okay . and , um- [doctor] and , in terms of your activities of daily living , are you able to exercise or anything like- [patient] yes , i do exercise in the morning . i , i ride , uh , our bike for probably about 45 minutes or so . [doctor] okay . all right . and then , your depression , you said it's ... how's that going ? i know we have you on the , on the prozac 20mg a day . are you taking that ? are you having a lot of side effects from that ? [patient] i was taking it regularly , but i've kind of weened myself off of it . i thought i felt a little bit better , but i think , uh , i , i kinda go through battles with depression every so often . [doctor] okay . all right . are you interested in resuming the medication , or would you like to try a different one ? [patient] i , maybe adjusting what i'm currently taking , maybe l- less of a dose so i do n't feel the side effects as much , but i , i'm willing to try something different . [doctor] okay . all right . okay , well , let's , let's go ahead and we'll do a quick physical exam . so , looking at you , you're in , in no apparent distress . i'm feeling your neck . there's no cervical lymphadenopathy . your thyroid seems not enlarged . and , listening to your lungs , you do have some bilateral expiratory wheezing that's very faint , and your heart is a regular rate and rhythm . your abdomen is soft , and uh , your lower extremities have no edema . so , let's go ahead and look at some of your results . hey , dragon , show me the pfts . [doctor] okay , so your , your pfts , that , those are your breathing studies , and those look quite good , so i know that you're wheezing right now , but , um , you know , i think that we can add , add , um , a regimen to that to help , to help you with your , um , exacerbations during the , the summer months , okay ? [patient] okay . [doctor] and then , let's look at your ... hey , dragon ? show me the hemoglobin a1c . okay , so your a1c , you're right , you know , over the past couple months is , you know , your blood sugar's probably been running a little high , so , you know , i know that you're gon na get back on your diet regimen , but , um , for right now , let's go ahead and we'll increase your metformin , okay ? [patient] okay . [doctor] um , and then , hey , dragon ? show me the chest x-ray . okay , good , and your chest x-ray looks fine , so we know that there's no pneumonia there . [patient] mm-hmm . [doctor] and , it's just is all just from your asthma . so , you know , my impression of you at this time , you know , from a diabetes standpoint , let's , let's increase the metformin to 1,000 mg twice a day . um , and , we will get a repeat hemoglobin a1c in three months , and i want you to continue to monitor your blood sugars at home . [doctor] from an asthma standpoint , let's continue you on the albuterol , two puffs , uh , every four to six hours as needed , and we'll add symbicort , two puffs twice a day during the summer , to kind of help prevent those exacerbations . and then , from a depression standpoint , we'll go ahead and start you on a different medication , zoloft , um , 25 mg once a day and see how you tolerate that . does that sound okay ? [patient] perfect . [doctor] all right . so , the nurse will be in soon , and she'll get you situated with all of that , okay ? [patient] great . [doctor] it was good to see you . [patient] same here . [doctor] hey , dragon ? finalize the note .

ASSESSMENT AND PLAN

Mr. Joseph Fisher is a 59-year-old male who presents for routine follow up of his chronic problems.

 Asthma.
 • Medical Reasoning: His symptoms are exacerbated during warmer weather, but his recent pulmonary function tests were normal.
 • Medical Treatment: Continue on albuterol, 2 puffs every 4-6 hours as needed. Add Symbicort 2 puffs twice a day during the summer to help prevent exacerbation.

 Depression.
 • Medical Reasoning: The patient self-weened from Prozac 20 mg daily due to side effects.
 • Medical Treatment: We will start him on a different medication, Zoloft 25 mg once a day, to see how he tolerates this.

 Diabetes Type II.
 • Medical Reasoning: Recent blood glucose levels and hemoglobin A1c were elevated.
 • Additional Testing: Repeat hemoglobin A1c in 3 months. Continue to monitor blood glucose levels at home.
 • Medical Treatment: We will increase metformin to 1000 mg twice a day.


[doctor] hi , andrew , how are you ? [patient] hi . good to see you . [doctor] it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] sure . [doctor] okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ? [patient] uh , so , over the the weekend , we've been moving boxes up and down our basements stairs , and by the end of the day my knees were just killing me . [doctor] okay . is , is one knee worse than the other ? [patient] equally painful . [doctor] okay . [patient] both of them . [doctor] and did you , did you injure one of them ? [patient] um , uh , i've had some knee problems in the past but i think it was just the repetition and the weight of the boxes . [doctor] okay . all right . and , and what have you taken for the pain ? [patient] a little tylenol . i iced them for a bit . nothing really seemed to help , though . [doctor] okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ? [patient] uh , saturday night it actually kept me up for a bit . they were pretty sore . [doctor] mm-hmm . okay . and any other symptoms like fever or chills ? [patient] no . [doctor] joint pain ... i mean , like muscle aches ? [patient] no . [doctor] nausea , vomiting , diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys . [patient] mm-hmm . [doctor] um , how are you doing with that ? i know that you told dr. gutierrez- [patient] mm . [doctor] . a couple of weeks ago . [patient] yes . [doctor] everything's okay ? [patient] so far , so good . [doctor] all right . and you're taking your immunosuppressive medications ? [patient] yes , i am . [doctor] okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ... [patient] no , n- nothing out of the ordinary , from what they reported . [doctor] okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ? [patient] uh , yes , i am . [doctor] you're taking it regularly ? [patient] on the clock , yes . [doctor] yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ? [patient] no , nothing out of the ordinary . [doctor] okay . and just in general , you know , i know that we've kind of battled with your arthritis . [patient] mm-hmm . [doctor] you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant . [patient] sure . [doctor] so other than your knees , any other joint pain or anything like that ? [patient] every once in a while , my elbow , but nothing , nothing out of the ordinary . [doctor] okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ? [patient] no . [doctor] no headaches ? [patient] no headaches . [doctor] anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , dragon , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good . [patient] mm-hmm . [doctor] your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ? [patient] perfect . [doctor] all right . does that hurt ? [patient] a little bit . that's tender . [doctor] okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur- [patient] mm-hmm . [doctor] . which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ? [patient] mm-hmm . [doctor] so let's take a look at that . [patient] sure . [doctor] hey , dragon , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history . [patient] mm-hmm . [doctor] okay ? hey , dragon , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised . [patient] mm-hmm . [doctor] and it looks like your kidney function is also very good . so i'm , i'm very happy about that . [patient] yeah . [doctor] okay ? so i just wan na go over a little bit about my assessment and my plan for you . [patient] mm-hmm . [doctor] so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed . [patient] okay . [doctor] okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , dragon , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ? [patient] you got it . [doctor] for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ? [patient] sure . [doctor] hey , dragon , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ... [patient] mm-hmm . [doctor] you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ? [patient] you got it . [doctor] you have any questions ? [patient] not at this point . [doctor] okay . hey , dragon , finalize the note .

ASSESSMENT AND PLAN

Andrew Perez is a 62-year-old male with a past medical history significant for a kidney transplant, hypothyroidism, and arthritis. He presents today with complaints of joint pain.

 Arthritis.
 • Medical Reasoning: The patient reports increased joint pain in his bilateral knees over the past weekend. Given that his right knee x-ray was unremarkable, I believe this is an acute exacerbation of his arthritis.
 • Additional Testing: We will order an autoimmune panel for further evaluation.
 • Medical Treatment: Initiate Ultram 50 mg every 6 hours as needed.
 • Patient Education and Counseling: I advised the patient to rest his knees. If his symptoms persist, we can consider further imaging and possibly a referral to physical therapy.

 Hypothyroidism.
 • Medical Reasoning: The patient is doing well on Synthroid and is asymptomatic at this time.
 • Additional Testing: We will order a thyroid panel.
 • Medical Treatment: Continue Synthroid.

 Status post renal transplant.
 • Medical Reasoning: He is doing well and has been compliant with his immunosuppressive medications. On recent labs, his white blood cell count was within a normal limits and his kidney function is stable.
 • Medical Treatment: Continue current regimen.