[doctor] hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on [patient] and i've been in a lot of pain it started about i would say probably about three days ago [doctor] okay [patient] started having pain on my left back [doctor] okay [patient] and since then i continued to have pain it is traveling a little lower it's gotten little low but i definitely have not passed it yet and i'm just in so much pain [doctor] okay so is the pain that you're having is it constant or does it come and go [patient] it's constant [doctor] okay [patient] all the time i ca n't get comfortable [doctor] alright are you able to urinate [patient] i am and this morning i actually started seeing some blood [doctor] okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes [patient] i've had it for probably this might be my third time [doctor] third time alright [patient] yeah i have n't had one in a while but yeah this is my third time [doctor] okay so have you noticed any nausea chills fever [patient] no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous [doctor] okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain [patient] yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working [doctor] okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved [patient] yeah usually usually about about three four days to pass it yeah [doctor] right so this is this is the looks like this is the third day [patient] yeah [doctor] so we are getting close there [patient] okay [doctor] yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff [patient] i was i have n't been great about taking it but i did get the blood pressure cuff [doctor] so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running [patient] like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty [doctor] okay [patient] and then the bottom number has been between seventy and eighty okay that i mean that's not too bad i think when you were first diagnosed you were up there in the [doctor] the one eighties which was really high [patient] right [doctor] so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that [patient] trying my best but doc i really like my french fries [doctor] yeah [patient] like [doctor] we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help [patient] yeah some help could be helpful okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright [doctor] so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday [patient] i have and those those have been pretty good they are like in the low one hundreds [doctor] okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday [patient] i do [doctor] okay [patient] i do take it [doctor] that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain [patient] no chest pain [doctor] no chest pain are you having any belly pain [patient] the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain [doctor] no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt [patient] yes [doctor] okay i'm gon na press here on your back is that painful [patient] yes [doctor] alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound [patient] that sounds good and i i just i just want this pain to go away so thank you [doctor] okay no problem

ASSESSMENT AND PLAN

1. Kidney stone.
 - Medical Reasoning: Patient presents today with symptoms consistent with kidney stones. She does have a history of kidney stones with this being her third episode.
 - Patient Education and Counseling: We discussed the importance of pushing fluids to help facilitate passing the kidney stone.
 - Medical Treatment: Prescription for oxycodone 5 mg every 6 to 8 hours as needed for pain was provided today. Tylenol is recommended for breakthrough pain. She will push fluids and has been provided with a urine strainer. Referral to urology was also provided due to her recurrent episodes.

 2. Hypertension.
 - Medical Reasoning: Patient is currently stable and has not had any elevated readings. Her blood pressure was slightly elevated today, however, this is due to her current pain level.
 - Patient Education and Counseling: We discussed the importance of home blood pressure monitoring with the goal of at least 3 times per week. She was also advised on the importance of diet modification with limiting salt to 2300 mg daily.
 - Medical Treatment: Continue Norvasc 2.5 mg. Continue with home blood pressure monitoring 3 times per week. Limit salt intake to 2300 mg daily.

 3. Diabetes.
 - Medical Reasoning: Patient is currently stable and has not had any elevated glucose readings.
 - Patient Education and Counseling: We discussed the importance of diet modification.
 - Medical treatment: Continue metformin 500 mg daily. Continue with home glucose monitoring before meals. Referral to a dietitian was provided.


[patient] hey bruce so see here my my notes here is you here he had positive lab work for hep c so how're you doing today [doctor] i'm doing okay but i'm a little bit anxious about having hep c i've really surprised because i've been feeling fine they had done it as you know a screen as just part of my physical so i'm really surprised that that came back positive [patient] okay so in the past have any doctors ever told you that you had hep c [doctor] no never that's why i'm i'm so surprised [patient] okay so just you know i need to ask do you have a history of iv drug use or you know have known any hep c partners [doctor] i mean i used to party a lot and even did use iv drugs but i have been clean for over fifteen years now [patient] okay that that's good i mean i'm i'm happy that you were able to to kick that habit i know a lot of my patients that i see you know they're still dealing with with those dements so i'm i'm i'm happy that you're able to do that so hopefully we can get you better okay [doctor] thank you [patient] so what about alcohol use is that something that you used to do a lot [doctor] i did i did i mean i i still have a beer here and there everyday but not as much as i used to [patient] okay and have you ever smoked before [doctor] i do smoke i smoke about one to two cigarettes per day i've cut down a lot but i'm just having a hard time kicking those less too [patient] yeah yeah and that that's something i've got to work on too because hep c along with smoking you know both of those are n't are n't good so hopefully we can help you out you know if your pcp has n't prescribe something for you already and possibly we can we can do that for you as well [doctor] okay [patient] so do you have any other medical conditions [doctor] no i'm actually other than that i just had my physical and i'm not taking any medications no i'm i'm pretty good otherwise [patient] okay and what conditions would you say run in your family [doctor] i have high blood pressure diabetes and depression [patient] okay [doctor] alright so let me go ahead and do a quick physical exam on you so i reviewed your vitals and everything looks good and on general appearance you appear to be in no distress no jaundice on the skin on your heart exam you have a nice regular rhythm rate [patient] regular rate and rhythm with a grade two out of six systolic ejection murmur is appreciated on your lung exam your lungs are clear without wheezes rales or rhonchi on your abdominal exam bowel sounds are present your abdomen is soft with no hepatosplenomegaly [doctor] hepatosplenomegaly yes let me i will change that one [patient] splenomegaly and on your muscle exam there is no gait disturbance or edema so i did we i was able to review your your results of your recent lab work and your hcv antibody test was positive so your your liver panel we did one of those and it showed an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so that's pretty good so let's talk a little bit about my assessment and plan for you so you do have hepatitis c so your initial labs were consistent with that hep c diagnosis and so you know i do n't know if you read much about hep c but hepatitis c is a viral infection that does affect your liver and you've most likely had it for several years now it it it most patients do n't see symptoms until years later so the next step that i would like to do is just confirm the diagnosis with some additional blood work so that includes checking your hep c rna and your hcv genotype and i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and we will do that by ordering an ultrasound elasto elastography with this information we will we we will be able to know how we can proceed as far as treatment right so how does that sound [doctor] i hmmm so i do have a wife and kids so should i be worried about them [patient] okay yeah so we can start with the same screening that you had for august first so we'll just let's do that hep c antibody test and i'll actually help you set up those appointments with your your family doctor and then we can just see you back in three weeks and based on the results you know we will take action as needed okay [doctor] okay that sounds good [patient] alright [doctor] alright [patient] my nurse will be in with those those orders [doctor] alright thank you [patient] alright thanks [doctor] bye

ASSESSMENT

Hepatitis C.

PLAN

After reviewing the patient's laboratory findings today, I have had a lengthy discussion with him in regard to his current symptoms. His initial labs were consistent with a hepatitis C diagnosis. I have recommended that we confirm the diagnosis with additional blood work including checking his hepatitis C RNA and HCV genotype. I have also recommended that we obtain an ultrasound elastography to evaluate for fibrosis of the liver.

 The patient is married with children and is concerned about their hepatitis C status. I advised the patient that his family should be screened and we will assist him with setting appointments with their primary care physician.


[doctor] alright brittany so i see that you are experiencing some right foot pain could you tell me what happened [patient] yeah well i was playing tennis and i was trying to you know volley the ball [doctor] mm-hmm [patient] it was like a double game and i was trying to volley the ball and i got in front of another player and actually ended up falling on top of my foot [doctor] alright [patient] and then yeah it kinda hurt i quickly then twisted my myself around her because i was trying to catch myself but then i started to feel some pain in my foot [doctor] mm-hmm okay have you ever injured that foot before [patient] yeah no sorry i injured my other foot before not this foot [doctor] okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing [patient] yeah that's fine [doctor] alright were you able to continue playing [patient] no i had to stop i actually it was like i had to be held from the field because i could n't put weight on my foot [doctor] i'm sorry okay so what have you been doing for the pain since then [patient] i wrapped it after a the game they had some ace wraps in their clubhouse and so i wrapped it up and then i iced it last night and i just kept it up on a pillow and then i took some ibuprofen [doctor] okay could you one more time when did this injury happen [patient] this happened about couple days ago [doctor] okay so did you say whether does the ibuprofen help at all [patient] yeah it helps a little bit but then you know it it you know after a while it wears out [doctor] okay and then have you experienced any numb numbness or tingling [patient] no no numbness [doctor] okay alright any loss in sensation [patient] no i mean i i can still feel like i can still feel my foot [doctor] okay alright that's good to hear so you were playing tennis is that what you normally do to work out [patient] i do i'm trying to learn but i can not afford tennis less lessons so me and my friends just hit the balls back and forth i do sleep [doctor] i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah [patient] that scares me [doctor] it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay [patient] okay [doctor] alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt [patient] no uh uh [doctor] okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions [patient] yeah do i have to do the surgery [doctor] so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with [patient] i just hate that word surgery doc [doctor] i know [patient] you know it scares me every time i mean especially with my foot i want to be able to walk again and so i just get really worried i mean how long is the procedure usually too [doctor] so it's actually [patient] have to be in the hospital [doctor] no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed [patient] i'm right handed [doctor] yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what [patient] i mean [doctor] uh uh [patient] does that mean i'm out for the rest of the season i mean i wan na be able to get back and play again i really am i'm getting a little better so i [doctor] mm-hmm [patient] i really wan na keep on playing my tennis with my friends but [doctor] yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there [patient] i suppose so [doctor] yeah [patient] okay [doctor] alright [patient] thank you [doctor] no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay [patient] okay [doctor] alright [patient] good [doctor] thank you [patient] thank you

ASSESSMENT

Right foot pain, consistent with a Lisfranc fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her x-rays revealed a Lisfranc fracture. We discussed treatment options for this and I have recommended that we proceed with surgical intervention. The plan is to proceed with a right foot ORIF and all indicated procedures. We went over the risk, benefits, and alternatives of the surgery. The risk include but not limited to continued pain, swelling, damage to surrounding tissue including nerves and blood vessels, numbness that could be permanent, infection, nonunion, malunion, failure of hardware, and need for further surgery. There is always a risk of amputation, heart attack, stroke, blood clots, pulmonary embolism, and death. There is a possibility of chronic pain and the inability to get back to the previous level of function. The patient wishes to proceed with the operation and she will follow up with me on the day of surgery. In the meantime, I have recommended that the patient attend formal physical therapy to strengthen her right foot.
 "


[doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened [patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april and we were at the courts plan and i went up for a shot and he's far more aggressive than with me than he is with you know his peers i guess he could say and so he he found me while i was going for a lap and then when i came down i kind of landed awkwardly and i kind of like rolled and twisted my my ankle so now it's it's hurting a bit like kind of on the outside you can you can even see it's it's bruised up and a bit swollen [doctor] yeah [patient] and yeah i've been having trouble walking and it just does n't feel solid really stable which is a problem i i recently got back into working out and i had been in a really good rhythm going to the gym [doctor] okay [patient] and i do n't want to disrupt that moments on because it took a lot for me to get back to a good place so [doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way [patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys [doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad [patient] yeah yes [doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too [patient] yeah a little bit [doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all [patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid [doctor] sure so it does n't quite feel stable [patient] yeah [doctor] okay okay i gotcha so i know you had an x-ray as you came in today and so i'm just looking at this x-ray here i'll show you on the screen right here i can turn my monitor towards you this is an ap lateral oblique and this is your right ankle so what we're looking at is a displaced lateral malleolus at the weber c level there's no evidence of medial or posterior malleolar fractures but this is a fracture on the lateral side of your ankle now based on the position it's a bit unstable that's why you're feeling some of that that instability when you're walking so for your diagnosis what i'm gon na put down is a lateral malleolar fracture and what i would recommend for that since it is in the location that it is is you're probably unfortunately gon na need surgery we're gon na wan na get that healed what that includes is putting some plate and some screws in and you're gon na be out for a little bit so i know you've been trying to work out and and you wan na get back on the court but but you may have to have to sit out for a little bit we'll get you some crutches [patient] how long it's a little bit because i'm also i i forgot to say i'm also i did volunteer to coach [doctor] great [patient] starting in april so [doctor] alright well [patient] how long [doctor] yeah you you're probably gon na be out for about three months but continue the coaching go ahead and and let's get you back out there we'll get you some crutches and and hopefully you can kinda you know get back on the court start coaching and then within that three months we'll we'll get you back out doing some exercise again [patient] okay [doctor] alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly [patient] yeah i i work from home so that that should n't be a problem it's just everything else i do n't know who is gon na walk my dogs and and do all this stuff that's rest of my family refuses to walk my dog so we'll figure it out [doctor] yeah i i'm a dog walker as well so alright sorry for the bad news but let's get you healed up so that we can get you back out doing everything you need to do [patient] alright thank you doctor [doctor] alright thanks

ASSESSMENT

Right lateral malleolar fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding treatment options. Recommendation was made for an open reduction internal fixation of the right ankle. We discussed the risks and benefits of the procedure as well as the postoperative recovery period following surgery. I advised that it will be 3 months before he can resume his exercise routine. In the meantime, I will prescribe meloxicam to reduce swelling. I recommended he ice and elevate the ankle as well. He will be given crutches to assist with ambulation.

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


[doctor] hi , louis . how are you ? [patient] hi . good to see you . [doctor] it's good to see you as well . are you ready to get started ? [patient] yes , i am . [doctor] louis is a 58-year-old male here for follow up from an emergency room visit . so , louis , what happened ? [patient] yeah . i was playing tennis on saturday . it was really , really hot that day , very humid . and about after about a half an hour i was very short of breath , i was struggling breathing . i thought i was having a heart attack , got really nervous . so , my wife took me to the er and , uh , everything checked out , but i was just very upset about it . [doctor] okay . all right . and how have you been feeling since that time ? [patient] uh , foof , probably , probably about six hours after we got home , i felt very light-head and very dizzy and then , sunday , i felt fine . i just thought it was worth checking up with you though . [doctor] okay . and have you been taking all of your meds for your heart failure ? [patient] i have . i have . i've been , uh , very diligent with it . and , uh , i'm in touch with the doctor and so far , so good , other than this episode on saturday . [doctor] okay . and , and you're watching your diet , you're avoiding salt . have you had anything salty ? [patient] i cheat every now and then . you know , i try and stay away from the junk food and the salty foods . but , for the most part , i've been doing a good job of that . [doctor] okay . all right . um , and i know that they removed a cataract from your eye- [patient] mm-hmm . [doctor] . a couple of , like couple months ago . that's been fine ? [patient] that was three months ago , thursday , and everything's been fine ever since . [doctor] okay . so , no vision problems . [patient] no . [doctor] okay . and you had a skin cancer removed about five months ago as well . you've had a lot going on . [patient] yeah . it's been a really busy year . an- and again , so far , so good . that healed up nicely , no problems ever since . [doctor] okay . all right . um , so , why do n't we go ahead and we'll do a quick physical- [patient] mm-hmm . [doctor] . exam . hey , dragon , show me the blood pressure . so , here , your blood pressure is a little high . [patient] mm-hmm . [doctor] um , so , you know , i did see a report in the emergency room that your blood pressure was high there as well . [patient] mm-hmm . [doctor] so , we'll have to just kind of talk about that . uh , but let's go ahead and we'll examine you . [patient] sure . [doctor] okay ? [patient] mm-hmm . [doctor] okay . so , you know , looking at you , your neck is very supple . i do n't appreciate any fibular venous distention . your heart is a regular rate and rhythm , no murmur . your lungs have some fine crackles in them , bilaterally . and you have trace lower extremity edema in both legs . so , what that means , essentially , is that you may have some extra fluid on board , um , from eating salty foods- [patient] mm-hmm . [doctor] . along with this history of your congestive heart failure . but , let's go ahead and look at some of your results . hey , dragon , show me the ecg . so , this is , uh , a s- a stable ecg for you . this basically shows that you have some left ventricular hypertrophy which caused your congestive heart failure . um , let's go ahead and review your echocardiogram . hey , dragon , show me the echocardiogram . so , in reviewing the results of your echocardiogram , it shows that your pumping function of your heart is a little low , uh , but it's stable . and , you know , i think that we know this and we have you on the appropriate- [patient] mm-hmm . [doctor] medication therapy . and then , i just wan na be reminded about , um , the results of your skin biopsy . hey , dragon , show me the skin biopsy results . okay . and in reviewing the pathology report for your skin cancer- [patient] mm-hmm . [doctor] . you know , it looks like they got all of that and everything's fine . [patient] yep . [doctor] so , you know , my impression of you at this time , for the shortness of breath that you had in the emergency department , i think it was an exacerbation of your heart failure . and you probably had some , what we call , dietary indiscretion , you ate some salty food which made you retain some fluid . [patient] mm-hmm . [doctor] so , for that , i'm going to prescribe you , you know , an extra dose of lasix 80 milligrams , once a day . and , um , we're going to , uh , put you on some carvedilol 25 milligrams , twice a day . okay ? [patient] okay . perfect . [doctor] um , and i think from a , a cataract surgery standpoint and your skin cancer removal , everything seems to be fine and you're doing well , so i do n't think we need to adjust any of those medications . [patient] good to hear . [doctor] okay ? hey , dragon , order lasix 80 milligrams , once a day . hey , dragon , order carvedilol 25 milligrams , twice a day . okay . and the nurse will come in and she'll see you soon . okay ? [patient] great . [doctor] hey , dragon , finalize the note .

ASSESSMENT AND PLAN

The patient is a 58-year-old male who presents for follow-up after emergency room visit.

 ED follow-up and congestive heart failure.
 • Medical Reasoning: I believe his symptoms which led to his ED visit were due to an exacerbation of his heart failure. He admits to some dietary indiscretion, which likely resulted in fluid retention.
 • Medical Treatment: I will prescribe Lasix 80 mg once a day. I will also place him on carvedilol 25 mg twice a day.

 Status post basal cell carcinoma removal.
 • Medical Reasoning: He seems to be doing well and the removal site is well-healed. No change in treatment is necessary at this time.

 Status post cataract surgery.
 • Medical Reasoning: He seems to be doing well. We will continue to observe, but no treatment changes are needed today.


[doctor] okay [patient] good morning [doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it [patient] sure absolutely what can i help you with today [doctor] so you know i've been dealing with my asthma and like i tried to join sports but it's really kind of it's getting hard you know and i i i just wonder if there's something that can be done because i really do like playing water polo [patient] but i'm having difficulty breathing sometimes i've had to like you know stop matches and sit on the side just to kind of like catch my breath and use my inhaler so i was wondering if there was something we could do about it [doctor] and then like i'm kind of a little bit worried i think my mood is getting a little a little worrisome and i i wanted to explore like what my options were [patient] okay let's talk about the asthma first so what inhaler are you using now [doctor] i have an albuterol inhaler [patient] okay and when when you're having trouble it's usually just around sports that is it keeping you up at night [doctor] so i do n't really like wake up at night a lot typically like it's sports like you know if i'm doing anything like crazy aerobic or like running or anything i do notice that if any if i'm around smoke i do start coughing a little bit but most of the time it's sports [patient] okay and can you describe a little bit for me what happens [doctor] i start to yeah no so i start to feel like there is like some phlegm building up in my in my throat and i start coughing like my chest gets tight i start wheezing and i just have to sit down or else i'm gon na get like lightheaded too [patient] okay and then when you use your inhaler [doctor] mm-hmm [patient] does it does it alleviate the problem [doctor] so yeah it helps with that like phlegm feeling you know but i still i still have to sit down you know and like breathe and then the thing that i hate about that inhaler is i start getting like shaky is that supposed to be happening [patient] yes that is unfortunately normal and a side effect with the inhaler [doctor] okay [patient] so you use you're using two puffs of the inhaler [doctor] mm-hmm [patient] for the symptoms [doctor] yes [patient] and then you sit down and does it does it get better within about fifteen minutes or so [doctor] yeah yeah it does but you know i had to like step out of the the pool to make that happen i'm hoping that there is something else we can do okay have you ever taken any daily medications for your asthma an inhaler or singulair or anything like that no i i just use my inhaler whenever i have an attack [patient] okay so that's something we might wan na consider but how often is it happening [doctor] pretty much every time i do any kind of aerobic workout [patient] okay and outside of physical activity you're not having any problems [doctor] yeah there's that part where like if i'm around somebody who has been smoking a lot or is currently smoking but i usually just step away i do n't even like to be around them you know that makes sense [patient] alright well we will look at that tell me about the mood issues you are having [doctor] yeah so one of the reasons i got into like trying to get into sports is like i feel like you know you you feel a lot more energized and a lot you know happier but like lately i've just been kinda stressed out you know like i have i have like sats that i need to study for i've got like all these ap classes you know there's just it i feel like there's a lot of pressure and you know like i get it but there are times where i'm just like really down and i i do n't really know what else i can do [patient] okay that makes sense any any difficulty with focusing or you're having difficulty retaining information or is it more feeling sad not having motivation [doctor] so i think it's like a lot of sadness a lot of like you know i do n't really i kinda feel like you know i do n't really like want to do anything you know my friends will go out and i'll just be like i'd rather be at home i am really tired a lot too [patient] okay alright well let me let me go ahead and check you out [doctor] mm-hmm [patient] and then we can talk a little bit more [doctor] okay [patient] i'm gon na take a listen to your heart and lungs [doctor] mm-hmm [patient] and everything sounds good [doctor] let me take a look at your eyes [patient] mm-hmm and in your ears everything looks okay have you had any problems with allergies you have seasonal allergies or anything like that [doctor] yeah i think so yeah [patient] i do see just a little bit of fluid in the ears [doctor] mm-hmm [patient] and i'm gon na look in your mouth too [doctor] okay [patient] and throat looks fine no tonsils [doctor] mm-hmm [patient] lem me go ahead and have you lay back on the table and i'll take a listen to your stomach [doctor] okay [patient] everything sounds okay i'm gon na feel around just to make sure everything feels normal [doctor] mm-hmm [patient] everything feels fine and i'm gon na check reflexes and they're all normal [doctor] awesome [patient] it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair [doctor] mm-hmm [patient] and start with that once you are on that daily and you can continue to use the albuterol inhaler those side effects unfortunately you're right it's it's just one of the expected side effects with an albuterol inhaler i would recommend just what you're doing just sit down for a little bit after you take it [doctor] and we will get you started on the singulair probably within about a month you should see a difference so i will have you come back in about six weeks and follow up and see how you're doing with that [patient] in terms of the mood is this new for you [doctor] yeah i think so like when i started this year [patient] and it sounds like related to school expectations and the stress with saps and all of that [doctor] yeah [patient] okay let's consider having you start seeing a therapist i think that would be a good place to start [doctor] mm-hmm [patient] and we will do some screening questionnaires and and then follow up in a couple weeks on that too [doctor] okay alright sounds like a plan okay [patient] thank you

ASSESSMENT AND PLAN

1. Asthma.
 - Medical Reasoning: The patient has experienced an increased need to use her albuterol inhaler. She is not currently utilizing a daily medication. At this time, we will try a daily medication since it looks like she might be having some allergies.
 - Patient Education and Counseling: I explained the side effects of albuterol to the patient. We also discussed Singulair and that she should start to see a difference in her breathing within approximately 1 month.
 - Medical Treatment: We will start her on a daily asthma medication. She can continue to use the albuterol inhaler. We will start her on Singulair in about a month.

 2. Mood.
 - Medical Reasoning: The patient reports being under a lot of stress with school. I believe this may be attributing to her mood.
 - Medical Treatment: I would like for the patient to be seen by a therapist. She will also complete our screening questionnaire.


[doctor] this is philip gutierrez , date of birth 1/12/71 . he is a 50-year-old male here for a second opinion regarding the index finger on the right hand . he had a hyperextension injury of that index finger during a motor vehicle accident in march of this year . he was offered an injection of the a1 polyregion , but did not want any steroid because of the reaction to dexamethasone , which causes his heart to race . he was scheduled to see dr. alice davis , which it does n't appear he did . he had an mri of that finger , because there was concern about a capsular strain plus or minus rupture of , quote ,  fds tendon ,  end quote . he has been seen at point may orthopedics largely by the physical therapy staff and a pr , pa at that institution . [doctor] at that practice , an mri was obtained on 4/24/2021 , which showed just focal soft tissue swelling over the right index mcp joint , partial-thickness tear of the right fds , and fluid consistent with tenosynovitis around the fdp and fds tendons . radial and ulnar collateral ligaments of the index mcp joint were intact , as the mcp joint capsule . extensor tendons also deemed intact . [doctor] his x-rays , four views of the right hand today , show no bony abnormalities , joint congruency throughout all lesser digits on the right hand , no soft tissue shadows of concern , no arthritis . hi , how are you , mr . gutierrez ? [patient] i'm good , how about you ? [doctor] well , how can i help you today ? [patient] so i was a passenger in , uh , a car that was rear-ended , and we were hit multiple times . i felt two bumps , which slung me forward and caused me to stretch out my right index finger . [doctor] so hitting the car in front of you all made that finger go backwards ? [patient] um , i do n't really know . i just felt , like , it felt like i laid on my finger , and so , i felt like it went back , and it's been hurting since about march . and it's been like that ever , ever since the wreck happened . so i , and i ca n't make a fist , but sometimes the pain's unbearable . and , like , even driving hurts . [doctor] okay , so this was march of this year , so maybe about three months ago ? [patient] yeah , and it's still swollen . so i was seeing , uh , an orthopedist , and they sent me to an occupational therapist . and i've been doing therapy with them , and then they sent me to go back and get an mri . so i went and got the mri . uh , then they told me that the mri came back , and it said i had a tear in my finger , but he was n't gon na give me an injection , because the injection was going to make the tear worse . [doctor] mm-hmm . [patient] and then , after he got the mri , he said that i have , uh , a tear in my finger , and that he did n't wan na do surgery , but he would do an injection . then i'm thinking that you told me you would n't do an injection in there , and then the oper- , occupational therapy says it's because of the tear . and then , they do n't want me to keep rubbing the thing , and doing things with my hand . so i feel like i'm not getting medical care , really . [doctor] yeah , i see that . [patient] so i came to see if you could do anything for this hand , because i am right-handed , and i kinda need that hand . [doctor] what do you do for a living ? [patient] uh , i'm an x-ray tech . [doctor] well , um , so do you have any diabetes or rheumatoid arthritis ? [patient] nope . [doctor] uh , do you take any chronic medications of su- , significance ? [patient] uh , i do take a blood pressure pill , and that's it . [doctor] okay , and it looks like you suffer from itching with the methylprednisolone ? [patient] uh , that's correct . [doctor] all right , well , i'm gon na scoot up closer and just take a quick look at your hand . all right , so , lean over here . all right , so on this exam today , we have a very pleasant , cooperative , healthy male , no distress . his heart rate is regular rate , rhythm , 2+ radial pulse , no swelling or bruise , bruising in the palm over the volar surface of his index finger , normal creases , slightly diminished over the pip of the index finger compared to the middle finger . [doctor] his index finger rests in a 10-degree pip-flexed , uh , position . all right , is that uncomfortable to correct that , and is it uncomfortable now here ? [patient] yeah , uh , when you push on it , yeah . [doctor] all right , how about here ? [patient] um , there , it's not . [doctor] okay , not as bad ? [patient] yeah , it feels , uh , a little numb . [doctor] gotcha , all right . bend , bend the tip of this finger . bend it as hard as you can . keep bending . keep bending . all right , straighten it out . all right , and now , bend it for me as best you can . [patient] my goodness . it feels like it's , it's tearing in there . [doctor] okay , okay . well , bend the tip of this finger , and bend it as hard as you can . keep bending . all right , straighten that out , and now , bend it for me as best you can . all right , good . now , bend that finger , and i'm going to pull , put it down like this . and then bend that finger for me . okay , sorry , can you bend it for me ? all right . now , make a fist . great , so relax the finger . all right , so just keep it , keep , when i bend the finger , we're just going to bend that finger where it meets the hand . is that okay there ? [patient] ow , . [doctor] okay , okay . so all the hurt , it seems , is stretching , because you have n't been doing this for so long . so , you know what i mean ? so , um , you're going to have to start really doing that . [patient] well , i've tried . i even bought myself a splint . [doctor] well , but a splint does n't help move you . it actually immobilizes you . [patient] okay . i thought it would straighten it out . [doctor] no , no . so , so you really need to start bending the finger right here for me , as hard as you can , and keep going , going . all right , so , so you're okay . all right , so i would say the following , that there is a partial tear in one of the two flexor tendons . there is the fdp and the fds , and the fds is the least important of the two . so the mri shows that it's the fds , the flexor digitorum superficialis , which is the least important of the two . [patient] okay . [doctor] uh , now , there's two halves of it . so it's a partial tear of one half of a whole tendon . that's not that important , and the other one is just fine . [patient] so the good one is good ? [doctor] yes , correct . so the one that goes all the way to the tip is good . [patient] okay , good . [doctor] yeah , so you know , i think what you have got so much scar tissue and inflammation around the fds tendon blocking excursion of these other tendons , that they ca n't get through to the pulley . [patient] okay , all right . [doctor] so what i would recommend what we try is a cortisone injection , and i would avoid the dexamethasone , because i saw you have a little reaction to that . but we could use the betamethasone , which is a celestone . [patient] i've gotten another , uh , methylprednisolone , and that itched me like crazy . [doctor] did it ? yeah , this one is water-soluble , and i think it's fairly low toxicity , but high benefit , and i think decreasing the pain will encourage you to move that finger . [patient] all right , we'll give it a try . [doctor] good . so , you do the shot , and it's going to take about three to five days before it starts feeling better . and then probably over the next couple of weeks , it'll start feeling even better . [patient] perfect . [doctor] all right , so take advantage of that . you've got ta start moving the finger . you're not going to tear anything or break a bone , uh , because your intensors , extensors are intact . but your collateral ligaments are intact , so you've got a stiff , sore finger . i'm going to try to help as much as i can with this soreness part , and then you have to do all the stiff part . [patient] the lady in occupational therapy tried some maneuvers to straighten the finger out , but it even hurt after i left . the whole thing just swelled up . [doctor] hmm . okay , so it was injured , and you had scar tissue . and then , you had post-traumatic inflammation . and so , this will help some with all of that . it's not going to make it to where your finger is like , , my finger does n't hurt at all , but it will make it to where at least tolerable , to where you can make some gains . and we actually might need to repeat this as well . [patient] will i be able to drive ? i drove myself here today , so ... [doctor] yeah , it may feel a little weird , but it's totally safe for you to drive . [patient] okay , good . [doctor] so for mr . gutierrez , just put that he has a post-traumatic rather severe stenosing tenosynovitis of his right index finger , and the plan is steroid injection today , do a trigger injection , but i'm using a cc of betamethasone . so , mr . gutierrez , do you have , um , therapy scheduled or set up ? [patient] uh , not at the moment . [doctor] all right , well , i mean , you know that you need to move that finger , and i think to the degree that they can help you do that . so i want you to move that finger , finger , but i think it would be , uh , beneficial for you to have an accountability , um , so at least you know to check in with them once a week with somebody . [patient] um , okay . that's kinda why i'm here , for you to tell me what needs to be done , you know ? [doctor] yeah , so i'll write you out , um , an outpatient prescription . i think if you go back to the same people where you were before , i'm hoping that after this injection , you're going to be able to do a whole lot more with them . so let's do outpatient once a week for six weeks , um , and then full active and passive range of motion is the goal with no restrictions . [patient] all right , sounds like a plan . [doctor] all right , well , i will have the nurse set up the injection procedure , and we'll , and i'll be back shortly . [patient] thanks , doc . [doctor] right trigger finger injection template . attempted to inject one cc of celestone with f- , a half a cc of lidocaine . however , the patient had a dramatic and violent painful reaction to the introduction of the needle , with contortions of the hand , and with dangerously withdrawing the hand with concerns for secondary needle stick . needle was withdrawn . the patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath . we attempted a second time for a similar injection using the same technique with one cc of celestone and half a cc of lidocaine . a small parma- , uh , palmar vein bled a scant amount , which was cleaned up and band-aid applied . reassured on multiple occasions that no harm was done to his finger . recommended icing in it this evening , and taking ibuprofen .

ASSESSMENT

• Stenosing tenosynovitis of right index finger.

 Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion of his right index finger hyperextension injury sustained during a motor vehicle accident in March of this year. The findings of his examination are consistent with rather severe post-traumatic stenosing tenosynovitis.

PLAN

The patient and I had a lengthy discussion regarding his history, symptoms, and radiographic findings. We discussed the pathophysiology and natural history of stenosing tenosynovitis and the anatomy of the flexor tendons and pulley system in the hand. I explained to the patient that the flexor digitorum superficialis tendon was clearly intact and that He is suffering from post-traumatic inflammation around the flexor digitorum superficialis tendon blocking excursion of the flexor tendons to the A1 pulley.

 Treatment options were discussed including conservative management with corticosteroid injections and their statistical effectiveness. Surgical correction was also briefly discussed, although I recommend exhausting non-operative measures with a minimum of 2 injections before proceeding with surgery. I recommended a right index trigger finger cortisone injection today, and the patient elected to proceed. I also recommend that the patient report to occupational therapy once a week for the next 6 weeks to work on full active and passive right index finger range of motion with no restrictions.

 The patient verbalizes understanding with the treatment plan and agrees. All questions were answered to the patient's satisfaction today.


[doctor] hi michelle what's been going on the medical assistant told me that you injured your knee [patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since [doctor] okay and were you able to ski down the hill or did you have to be taken down by the ski patrol [patient] i had to be taken down by the ski patrol i was unable to bear weight [doctor] okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside [patient] it hurts on the outside but it also feels like it wo n't hold my weight [doctor] okay so it feels like it's gon na buckle [patient] hmmm yes [doctor] okay alright and are you able to bend it [patient] i was immediately after the injury but not really now [doctor] okay and how about straightening it are you able to straighten it at all [patient] somewhat but it really hurts when i try to straighten all the way [doctor] okay alright now do you have any numbing or tingling in your toes [patient] no [doctor] okay and can you feel your toes okay [patient] i think so [doctor] okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do [patient] i chase my two four -year-old [doctor] okay do you have twins [patient] i do [doctor] nice that's great [patient] yeah [doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or [patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids [doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy [patient] yes [doctor] okay and no high blood pressure diabetes anything like that [patient] mm-hmm [doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again [patient] my right knee [doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press [patient] yes [doctor] okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain [patient] ibuprofen [doctor] is that helping [patient] somewhat yes [doctor] okay alright do you want something stronger [patient] no i'm okay [doctor] alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured [patient] hmmm no i not i i would like to get back to the running but currently not that active [doctor] okay alright alright do you have any questions about anything [patient] i think you've explained it well [doctor] okay alright so i'll see you again soon okay [patient] okay thank you [doctor] alright take care bye

ASSESSMENT

Right knee pain, possible ACL tear.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate for a possible ACL tear. In the meantime, I have advised her to continue taking ibuprofen 600 to 800 mg every 8 hours as needed for pain. She will also be placed into a brace for increased knee support.


[doctor] hey diana it's good to see you in here so i see that you injured your wrist could you tell me a bit about what happened [patient] yeah i was walking up and down the stairs i was doing my laundry and i slipped and i tried to catch myself and i put my arms out to catch myself and then all of a sudden i just my wrist started to hurt real bad and it got real swollen [doctor] wow okay so which wrist are we talking about left or right [patient] it's my right one of course [doctor] okay and then have you ever injured this arm before [patient] no i have not [doctor] okay alright so on a scale of one to ten how severe is the pain [patient] gosh it's like a nine [doctor] wow okay have you done anything to ease it [patient] yeah i did the ice thing i put ice on it and then i you know i even i have a ace wrap at home i try to do that [doctor] mm-hmm [patient] and then i took some ibuprofen but it helps a little bit but it's just it's it's just not right [doctor] okay [patient] really [doctor] yeah okay have you sorry i'm trying to think how long ago did this injury happen [patient] this happened yesterday morning [doctor] okay [patient] maybe just you know i just bumped it but [doctor] okay [patient] it's just not it's really bad [doctor] okay no i understand okay so i'm going so you said you were doing laundry [patient] yes i had my back hit my basket and for some reason this cold started to kinda fall out a little bit i was trying to catch it i missed a step and i just totally [doctor] okay alright any does the pain extend anywhere [patient] no not really [doctor] okay [patient] it's just really along my wrist [doctor] okay any numbness any tingling [patient] a little one and one ca n't tell if it's just because of the swelling in my wrist but just i can like i can feel it my fingers still [doctor] mm-hmm [patient] but just maybe a little bit of tingling [doctor] okay alright and are you so so okay i'm gon na think on this but in the meantime i'm gon na do my physical exam alright [patient] okay [doctor] okay so you know looking at your looking at your head and your neck i do n't appreciate any like adenopathy no thyromegaly no no carotid bruit looking at your listening to your heart i do n't appreciate any murmur no rub no gallop your lungs are clear to auscultation bilaterally your lower legs you have palpable pulses no lower edema your shoulders every like your upper extremities i see normal range of movement with your right wrist let's go ahead and focus on it so when i push on the inside here does it hurt [patient] yes [doctor] okay [patient] it does [doctor] and what about the outside does that hurt as well [patient] yeah it does [doctor] are you able to move your wrist towards your arm like [patient] not without extreme pain [doctor] okay so pain on flexion what about extension when you pick your wrist up [patient] yeah i have a hard time doing that actually [doctor] alright what about we're gon na go ahead and hold your arm like straight like flat and then try and move it sideways does radial deviation hurt [patient] yeah [doctor] alright and then lateral as well [patient] yeah it's really hard to move any direction of this hand for some reason [doctor] alright so wrist abduction adduction positive for pain on movement are you able to make a fist [patient] hmmm yeah a little bit but i ca n't do it really tight [doctor] okay alright okay so i'm just gon na go ahead and feel on your fingers really quickly alright metacarpals intact noticed some obvious swelling ecchymosis obvious swelling and bruising tenderness on palpation throughout there is evidence of potential fracture feeling some bony crepitus alright so this pain is it like chronic i wanted to ask you [patient] yeah i would say it kinda goes away when i take that ibuprofen but for the most part i feel it i feel it there and it it's just really really bad when i move it all [doctor] okay so when you like is there a position either hurts less or hurts more like say if your arm is raised and elevated over your head does it hurt more or is it just best to keep it like down [patient] it's good if i keep it a little bit above my like a little i guess a little bit like around my like just a regular level like if you're typing or something and then i just put it on a pillow and i just let it stay straight like i feel better [doctor] okay yeah no i do n't think i understand completely okay so i took a look at your vitals and your blood pressure is a little elevated but honestly that's probably to do with the pain right our body can respond to pain in that way we are looking at like a hundred and forty over over seventy it's not anything crazy but something to mention i see that your heart rate is also a little elevated at like about like eighty beats a minute you are not running a fever so that's great look at ninety ninety seven . two your respiratory rate is pretty normal at like twenty so before we came in i i know that we had you do an x-ray and i'm sure that that was a bit more painful because we had to do so many manipulations but i do wan na note that you are positive for what we call a colles' fracture what that means is that the joints between your wrist like the bones between your wrist that there there is evidence of a a fracture and we are gon na have to treat it a little conservatively at first and then consider some of the options options that are available to us so for your primary diagnosis of a colles' fracture we are going to give you a thumb spica for today and that's going to [patient] i'm sorry [doctor] pardon what [patient] a what [doctor] we're gon na brace you we're gon na give you a brace [patient] okay thank you [doctor] sorry no problem sorry yeah not a thumb spica we're gon na brace your arm and you're gon na have that we we have a couple of options but i think the best course of action is gon na be for surgery we will in the meantime give you pain medication i wan na put you on fifty milligrams of ultram every six hours and then i also wan na get you on get you into physical therapy a few weeks after surgery this is gon na be just a normal procedure you will be in for an overnight stay but after that once we assess and make sure that everything is good you'll be able to go home okay [patient] when do i have to have the surgery [doctor] we would like it to happen as quickly as possible you know your body is a wonderful miracle and it's going to start trying to heal on it's own what we need to do is get your wrist straight and then like put screws in to make sure that we hold it in place or else it could like heal and malform [patient] okay [doctor] alright so what [patient] how how long do i have to wear that brace [doctor] you're gon na be wearing the brace for about six weeks [patient] six weeks [doctor] yeah so you're gon na you're gon na come in for your surgery we're gon na perform it you're gon na stay overnight and then you'll be bracing it for six weeks in the meantime you'll also then go to physical therapy i want you there like we're gon na they're gon na do an assessment and determine how much but i'm thinking probably three times a week just to make sure that you can get your wrist as strong as possible to prevent like future injury now the cool thing about getting any kind of a bone break is that your your body comes out even stronger so this should n't happen again but unfortunately like it's these situations that oof that just kind of [patient] oof [doctor] these these deform these deformities that really that really kind of hurt is the short version alright no problem any other questions [patient] no well i am going on vacation do i need to cancel it like can i still go even with the i mean after the surgery [doctor] yeah [patient] do it as soon as possible i'm going a vacation in a month so [doctor] okay how long is the vacation [patient] it's only for like a couple weeks [doctor] okay well so you might have to postpone it just because depending on what physical therapy says right if they feel that you can sustain if you can like sustain the exercises while you're gone that if there's something that you can do by yourself then you should be fine but we do wan na give it you said that it's gon na happen in a couple of weeks [patient] no vacation in a month [doctor] okay okay yeah so how about in a month we come you come back let's do a checkup again see where we are at and then we can assess whether or not this is something that i would recommend you do [patient] that sounds good thank you [doctor] no problem bye [patient] bye [doctor] the fracture appears extra-articular and usually proximal to the radial ulnar joint dorsal angulation of the distal fracture fragment is present to a variable degree if dorsal angulation is severe presenting with a dinner fork deformity ulnar styloid fracture is present

ASSESSMENT

Right wrist Colles fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays revealed a right wrist Colles fracture. We discussed treatment options and I have recommended that we proceed with a right wrist ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I explained that we should schedule the operation for as soon as possible to ensure adequate healing and to limit malformation of the wrist. I advised that this procedure will require her to be admitted to the hospital for an overnight stay.

 In the meantime, the patient will be placed in a thumb spica brace and receive instructions on its proper usage. I have prescribed the patient Ultram 50 mg every 6 hours to treat her pain. We also discussed that her postoperative course will include wearing a brace for 6 weeks. A few weeks after surgery, the patient will initiate formal physical therapy and will attend 3 times per week to strengthen her right wrist. The patient has a 2-week vacation planned in 1 month. I recommended that we consult with her physical therapist to determine if there are exercises she can perform on her own instead of postponing her vacation.


[doctor] hey lawrence . how are you ? [patient] hey , good to see you . [doctor] it's good to see you too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ? [patient] uh , i , i've noticed that i've been swelling up a little bit . i think a lot of it has to do with going to some house parties , eating some salty foods . i feel really lethargic . [doctor] okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ? [patient] it's something like walking up a flight of stairs i'll actually feel it . [doctor] okay . all right . now , um , how long has this been going on for ? [patient] probably about 10 days . [doctor] okay . all right . and you said you're noticed some swelling in your legs ? [patient] a little bit . [doctor] okay . do you have problems lying flat in bed ? [patient] um , i'm a little uncomfortable when i wake up in the morning and i feel pretty stiff . and , and , like , it takes me a little while to adjust to walking when i get up . [doctor] okay . all right . do you ever wake up acutely short of breath at night ? [patient] um , it happened once , probably about a week ago , but it has n't happened since . so i have n't been that concerned about it . [doctor] okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump . [patient] mm-hmm . [doctor] um , are your blood sugars okay ? have you noticed a spike in them recently ? [patient] um , i have n't . i've been pretty good about monitoring it so i ... during the working week , i stay on top of that . but on saturdays or sundays we're so busy i forget to monitor it . but i have n't seen anything spike . [doctor] okay . and i remember your affinity for chocolate bars , so ... [patient] guilty as charged . i love chocolate bars . [doctor] okay . all right . so , in terms of your depression , how are you doing with that ? [patient] uh , it's been a crazy year and a half . um , i've tried some natural solutions . in the summer i did stretches outdoors every morning , which was great , but now the weather changed and , uh , you know , i've got ta find some alternatives . i'm not ready to try any medications just yet , so- [doctor] okay . [patient] . i'm open to some suggestions . [doctor] okay . we'll talk about that . [patient] sure . [doctor] and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole . [patient] mm-hmm . [doctor] you were making some lifestyle modifications , cutting back on your red bull and caffeine . [patient] yeah . [doctor] alcohol intake has been ... how's that been ? [patient] tough during the holiday season , but i'm , i'm better . [doctor] okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ? [patient] no . no . absolutely not . [doctor] okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath . [patient] mm-hmm . [doctor] any other symptoms ? chest pain , fever , chills , cough ? [patient] no . [doctor] um , belly pain ? [patient] no . [doctor] okay . let's go ahead . i want to move on to a physical exam . [patient] mm-hmm . [doctor] hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find . [patient] mm-hmm . [doctor] okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion . [patient] mm-hmm . [doctor] but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ? [patient] okay . [doctor] hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good . [patient] mm-hmm . [doctor] so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every day . [patient] mm-hmm . [doctor] if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911- [patient] mm-hmm . [doctor] . and go into the emergency room . you might need some intravenous diuretics . [patient] mm-hmm . [doctor] okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ? [patient] sure . [doctor] no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ? [patient] not at this point . [doctor] okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ? [patient] you got it . [doctor] hey , dragon ? finalize the notes ...

ASSESSMENT

Lawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath.

PLAN

Acute heart failure exacerbation.
 • Medical Reasoning: The patient is retaining fluid. He has noticed increased fluid retention following dietary indiscretion. He has experienced dyspnea on exertion for the past 10 days.
 • Medical Treatment: Initiate Lasix 40 mg a day.
 • Patient Education and Counseling: I advised the patient to monitor and log his daily weights. He will contact me if these continue to increase. He was instructed to call me or 911 if he experiences dyspnea at rest.

 Type 1 diabetes.
 • Medical Treatment: This is currently stable with use of an insulin pump.
 • Additional Testing: I will order a hemoglobin A1c in 1 month.
 • Medical Treatment: He will continue the insulin pump. The patient will follow up with his endocrinologist.
 • Patient Education and Counseling: I encouraged the patient to have an eye exam.

 Depression.
 • Medical Reasoning: The patient has been doing well with outdoor stretching. He continues to decline the use of medications for this issue.
 • Medical Treatment: I will refer him to psychiatry as his current management strategy is unsustainable due to the change in season.
 • Patient Education and Counseling: We will defer initiating medication at this time.

 Acid reflux.
 • Medical Reasoning: His symptoms are stable with medication.
 • Medical Treatment: Continue omeprazole 20 mg a day.


[patient] miss edwards is here for evaluation of facial pain this is a 54 -year-old male [doctor] how're you doing doctor cruz nice to see you today [patient] good to see you mister edwards i'm doctor [doctor] tell me what's been going on yeah so i've got this stabbing shooting pain i've had for a while you know and it it especially right here in my right face right in that cheek bone area it's sometimes it gets super hot i've had it for i think a couple of months now and i went to my family doctor and they said i should come see you [patient] okay great i would like to ask you a little bit more about that [doctor] had in your face do you remember how long that you had it probably for about two or three months just just came on slowly i started noticing it but now it's i have episodes where just shooting stabbing kind of a pain in my right cheek bone right face area [patient] mm-hmm do you have any sensory loss meaning like numbness or tingling in that part of your face [doctor] not that i've noticed no okay do you have any symptoms like this anywhere else on your face including the other side of your face [patient] no it's just on the right side mostly not on the left side just on the right side of my face [doctor] have you noticed any weakness on that side of the face like when you smile or while you're doing other things any weakness there not really i mean i've i've i've tried to you know when i smile my smile seems equal on both sides my eyes i do n't have any weakness there my vision seems to be unchanged but just this stabbing severe pain it's just like excruciating pain that i get sometimes does it happen on its own or there are certain things that trigger it [patient] sometimes if i'm if certain temperatures seem to trigger it sometimes or if it's super where it's cold i get a trigger sometimes [doctor] sometimes certain kind of sensory outside of the wind sometimes that seems to trigger it but that's about it [patient] okay and anything that you've done to to that helps for a little bit when you [doctor] pain excess [patient] you know i've tried ibuprofen and motrin that had really has n't helped it just comes on suddenly and then it's kinda stabbing excruciating pain i've tried rubbing some you know some tiger balm on it that did n't work [doctor] but that's you know so i i went to my family doctor and he said you know i really need to see a neurosurgeon [patient] got it how long do these episodes last these pain [doctor] you know it can last for anywhere from a few minutes to sometimes about an hour but generally generally a few minutes [patient] any history of something like multiple sclerosis or any brain tumors that you know [doctor] no nothing like that alright any other kinda headache symptoms that have anything like you had migraines or anything related to the headaches i mean i get occasional headaches but not really i do n't have a history of migraines but i occasionally get headaches like everybody else i take some tylenol that usually goes away but this is different [patient] how severe is the pain on a scale of one to ten [doctor] when it comes on it's like a ten it's like somebody is stabbing you with an ice pick and but usually you know after a few minutes usually it goes away but sometimes it can last up to an hour great so mister i would like to do a physical exam if that's okay with you [patient] sure [doctor] i would like you to follow my finger here and i see that you're following my finger in in both directions can you show me your teeth [patient] that looks nice and symmetric i'm gon na rub my fingers next to your ear can you hear that [doctor] yep [patient] you can hear it on the other side as well [doctor] yep [patient] okay [doctor] i'm gon na take this cotton tape and run it along the side of your face can you feel that okay [patient] yeah it's a little bit numb on my right side not so much on my left side [doctor] okay alright i'm gon na use this little needle here and i'm gon na poke here and i wan na see if you feel like it's being sharp or dull on that part of your face does that feel different or normal [patient] it feels a little bit dull on my left on my right side my left side it feels sharp [doctor] alright good well i had a chance to look at your mri [patient] okay [doctor] and i looked at your mri and it appears to have small blood vessel that is abutting and perhaps even pinching the trigeminal nerve the trigeminal nerve is nerve that comes from the brainstem that goes out to the face and provides the sensory inflammation from the face and you may have a condition called trigeminal neuralgia [patient] okay [doctor] where the nerve compression causes this kind of shooting electrical pain in the face how do we treat it [patient] well the first line would be to try some medications usually we start with medications that are called gabapentin [doctor] or tegretol these are medications that really help reduce the excitability of the nerve [patient] okay [doctor] most people can get the pain control with that but there are some people where the medications are n't gon na be enough and in that situation we would consider surgery i would n't i would n't recommend that now we usually try the medications first [patient] for considering a surgery to decompress the nerve the root cause of the problem is the compression of the blood vessel against the nerve [doctor] okay so we should be tried which one would you recommend the tegretol or yeah i think we could start with the tegretol to start with i just want to make sure that you understand some of the potential side effects that you can have with this [patient] sure [doctor] it's always a little bit of trial and error to figure out what the right dosing that would work for you but some common side effects can include you know memory loss tingling imbalance some people can actually have like dermatologic [patient] skin reaction to this medication and particularly people who have eustachian descent so that we may do some genetic testing just to make sure that it will be safe for you [doctor] okay sounds good let's do it [patient] okay so i will prescribe that for you and then we will see how that goes and if your pain continues we can talk about different surgical options to treat the pain [doctor] yeah i think i would like to try the tegretol first and if that does n't work then i can come back and so once should i come back and just to kinda check back with you and see if you know if it's had enough time for a fact or not [patient] i think one month would be a great time to follow up [doctor] okay sounds good so if you want to send that prescription over to my pharmacy that would be fine and then why do n't i come back in about a month and we'll go from there [patient] great i'll see you then [doctor] alright

ASSESSMENT AND PLAN

1. Trigeminal neuralgia.
 - Medical Reasoning: The patient has been experiencing facial pain for 2 to 3 months. A recent MRI revealed a small blood vessel abutting, or perhaps even pinching, the right trigeminal nerve. The root cause of his facial pain is the compression of the blood vessel against this nerve.
 - Patient Education and Counseling: The patient and I discussed treatment options including medicating with gabapentin or Tegretol. I explained the common side effects associated with these medications can include memory loss, tingling, and imbalance. We discussed the need for genetic testing due to the possible side effect of dermatologic reactions in people of East Asian descent. We also briefly discussed surgical treatment to decompress the nerve, but this is not recommended at this time.
 - Medical Treatment: A prescription for Tegretol will be sent to the patient’s pharmacy.


[doctor] hey george how are you today i understand you're here for some numbness and tingling in your fingers and some pain in your wrist [patient] right my right wrist and hand has been bothering me probably for a few months now with pain and numbness [doctor] okay and you said that's been ongoing for several months do you know what caused this type of pain or is it just something that started slowly or [patient] it just kinda started on it's own it i notice it mostly at night [doctor] okay [patient] sometimes it will i'll wake up and my hands asleep and i got ta shake it out [doctor] shake it out and okay [patient] and then some [doctor] what kind of work do you do [patient] i do yard work [doctor] yard work [patient] landscaping landscaping [doctor] landscaping okay so a lot of raking a lot of digging so a lot of repetitive type movements [patient] yeah it's pretty heavy labor but it's yeah the same thing day in and day out [doctor] okay okay just a couple questions for you you did say that you have the pain at night in that and you have to you get that numbness into the hand is it in all the fingers [patient] yeah it seems to happen to all my fingers but i notice it more in my thumb and pointer finger [doctor] okay okay and anything into that little into your fifth finger your little finger any numbness there at times no [patient] sometimes yeah it seems like it's numb too [doctor] okay what about your right hand any problems with that hand [patient] no i do n't seem to have any problems with my right hand so far it's just mostly my left [doctor] okay okay good and just a couple you know do you how do you have many or do you drink often do you have you know many any alcohol consumption [patient] i drink usually a a beer or two on fridays and saturdays on the weekends [doctor] okay and do you have any evidence of any anybody ever said that you had some rheumatoid arthritis in your hand or wrist anything like that [patient] no nobody say anything like that so i mean [doctor] okay okay good so let me go ahead and do a physical exam here real quick and you know i'm gon na quickly just listen to your heart and lungs okay that's good i'd like you to squeeze i'm gon na hold your hands here and i'd like you to squeeze both hands [patient] okay [doctor] you seem a little bit weaker on that left hand is that what you've noticed [patient] yeah i i i experienced some weakness in my left hand [doctor] okay do you you find that you're dropping things when you're picking it up is it to that level or [patient] yeah i drop things mostly because i have a hard time feeling it [doctor] okay okay good and so you you do have a a grip strength is less on the left and i just wan na touch your fingers here on the on the right side you can feel me touching all the fingers on the right [patient] yeah i can i can say you touch me but it feels a little more weird on the thumb side than my pointer finger side [doctor] okay okay and i wan na turn your wrist over here and turn your hand over and i'm gon na go ahead and tap on the right wrist on the back here does that do anything when i do that [patient] i still i feel a little jolt or a zing in my finger tips [doctor] okay and then when i do that on the left side [patient] yeah same thing [doctor] same thing okay so you do have a bilateral positive tinel's sign so so here's here's where i'm at i think your your diagnosis is beginning to have some bilateral carpal tunnel syndrome usually we see that with repetitive actions such as the landscaping the heavy labor and you you know your your clinical exam and and history sound like it's a carpal tunnel syndrome i do want to order so where are we gon na go from here i would like to order a a study it's called an emg where it it measures some of that electrical impulses down into your fingers we will follow up with that but as far as your treatment so the treatment for carpal tunnel syndrome is really some activity modification now i know you are a landscaper is there any way that you could be work to have some lighter work during the time [patient] i suppose i could try to pass it off to some of my other employes and delegate [doctor] okay that would be good so that's i i just want you to kinda eliminate that the active repetitive motions that you're doing all the time just for a couple weeks i'm also gon na give you a wrist splint to wear and that should help and i'd like you to take ibuprofen six hundred milligrams every six hours and then i wan na see you back here in the office in two weeks and in that two week period i think we're gon na see if there's need for any other intervention if i need to do more diagnostic testing or if there is a possibly looking at a surgical intervention to release that pressure that's on the nerves in that hand does that sound like a a good plan for you [patient] yeah it sounds like a good first start [doctor] okay okay so i i just just off off the record here what kind of what do what do you specialize in landscaping is your company do [patient] mostly like yard work and maintenance flower beds not really designing just up keep [doctor] okay yeah i'm looking for a landscape designer i need somebody to put in some elaborate walkways back through the backyard so yeah we can do stuff like that i mean if you have an idea what you want i think that's easy [patient] okay [doctor] you know if you're looking for like some [patient] backyard elasis rehab remodel that's i mean i suppose we could do we have n't done things like that in a while because we're busy enough with just the up key but it's something to explore [doctor] okay yeah i may have to keep that in mind because i do wan na do some of that so let's listen i'm gon na get my my nurse in here to discharge you do you have any other questions for me before we end this [patient] no i think it's all clear i appreciate it [doctor] okay take care and i'll look forward to see you in two weeks [patient] very good appreciate your time

ASSESSMENT

Bilateral carpal tunnel syndrome.

PLAN

After reviewing the patient's clinical history and examination today, I have had a lengthy discussion with him regarding treatment options for his current symptoms. I discussed the importance of activity modification and encouraged the patient to limit active repetitive motions while working for the next 2 weeks. I also recommended that he wear a wrist splint to provide increased support. I advised him to take ibuprofen 600 mg every 6 hours. Additionally, I recommended we obtain an EMG of the bilateral upper extremities to evaluate for carpal tunnel syndrome. The patient will follow up with me in 2 weeks when the EMG results are available for review. If at that time his symptoms have not improved with these conservative measures, we will discuss further treatment options including additional diagnostic testing or possible surgical intervention.

 The patient states he understands and is in agreement with the plan. All questions were answered to the patient's satisfaction.