[doctor] hi jeremy how are you [patient] i'm really good thank you how are you [doctor] i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks [patient] yes [doctor] going away [patient] yeah it's been there gosh it's like six or so weeks right now and it's and it's on my right foot and it's just yeah it's just not going away i'm not sure if it maybe even gotten a little worse from when i first noticed it [doctor] okay and how long did you say it's going on for [patient] probably about [doctor] six eight weeks maybe [patient] okay and do you have any pain in your foot no no no pain at all okay now i know that you're a diabetic and you are on some insulin have your sugars been running okay yeah they have been running [doctor] okay [patient] you know on the most part they seem to be running a little higher than normal [doctor] your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine [patient] yes it it it definitely was higher than nine [doctor] okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or [patient] yeah i was you know i think initially i'm you know i was out in the backyard you know kind of you know doing some work and you know i know i you know i could've stepped on a nail or you know there was some other work but you know i'm always outside so i do n't know if that kind of led to anything or caused anything [doctor] okay alright and have you had any fever or chills [patient] no no no fever or chills you know i kinda you know get headaches pretty often i do n't know if that you know i do n't know if that's a stress or but you know always have like the tension headaches in the front [doctor] okay and do you have do you have neuropathy where you get like numbing and tingling in your feet [patient] occasionally yeah occasionally especially when it's like colder outside [doctor] mm-hmm kinda feels like it takes a little longer to [patient] warm up but yeah i kinda have some sensation in in all my extremities [doctor] okay alright and then are you are you a smoker or did you smoke [patient] i did back you know kind of years ago i did but yeah i have n't smoked anything in in good number of years [doctor] okay alright when did you stop smoking [patient] couple years ago maybe four or so years ago [doctor] okay alright and how many packs a day would you smoke [patient] gosh back then yeah was at least two [doctor] okay alright how many years did you smoke for like twenty [patient] yeah at least twenty yeah twenty plus years [doctor] okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk [patient] no no no no pain you know just kind of you know it's just i know that it's there [doctor] okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no [patient] no no you know it's you know i just kinda feel like i've been just trying to take it easy lately [doctor] mm-hmm [patient] but yeah most most of the stuff i've been doing is just kind of hanging around the house [doctor] okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin [patient] i am yes yeah i do the baby aspirin every day [doctor] okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything [patient] okay and do you have a podiatrist for your yearly foot exams [doctor] no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here [patient] no [doctor] there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help [patient] any questions [doctor] yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay [patient] sure [doctor] sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay [patient] okay perfect [doctor] alright [patient] perfect thank you so much [doctor] okay bye

ASSESSMENT

1. Non-healing ulcer, right foot
 2. Diabetes
 3. Coronary artery disease

PLAN

After reviewing the patient's examination findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his right foot ulcer is fairly sizable and will require wound care. I advised him that the ulcer does not appear to be healing and that further studies will be needed to assess if he has adequate blood supply to heal his foot wound. He was advised that due to his diabetes it is possible surgical intervention such as stent placement or bypass surgery may be required to improve his blood supply. I also advised him that I believe we will be able to heal his wound. At this time, I have recommended continued wound care and for him to also continue taking aspirin 81 mg daily. We will order an arterial ultrasound of the lower extremities. He will also be referred to podiatry for a consult.

 Regarding his diabetes, this appears to be unstable as the patient reports his last hemoglobin a1c was greater than 9 and is now experiencing a non-healing right foot ulcer. We discussed the importance of blood sugar control as this will impact his wound healing. At this time, I have recommended that he follow-up with his primary care physician for further care.

 The patient's coronary artery disease is currently stable. It is recommended that he continue to take his statin as prescribed. I will contact his cardiologist for medical clearance should surgical intervention be required for his non-healing right foot ulcer."


[doctor] hey william so i see that you injured your knee could you tell me a bit about what happened [patient] yeah i thought it was a good idea to go to the trampoline park with my wife and heard a snap and instant pain when i was on the trampoline [doctor] okay alright and so do do you go to the trampoline park often [patient] i do n't and i think that's the issue [doctor] okay so this is the first time you'd ever done something like that [patient] yes [doctor] okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class [patient] no it's just for fun [doctor] okay and do you have like a regular exercise regimen at all [patient] try to not consistent with it [doctor] okay no that's fine this is not a place of judgment i just i'm just trying to understand like if a little bit more of the background okay so we went to the trampoline park which knee where did you hurt [patient] my right [doctor] okay your right knee and so based on like your inside and outside which part hurts more [patient] it's kind of the outside of the knee [doctor] alright so the lateral aspect not a problem and you said that you heard a pop when you landed right [patient] yeah [doctor] okay have you taken anything for the pain [patient] just tylenol [doctor] alright so did the tylenol help [patient] not really [doctor] okay alright and so hmmm when does it have you tried anything else like did you ice it use heat anything like that [patient] no i just kinda elevated it and that was about it [doctor] okay that's fine and how long ago did this happen [patient] a week ago [doctor] okay alright so you put up with the pain for a week that's i'm proud of you for that [patient] i do n't like to come to the doctors [doctor] excuse me i feel rejected right now why why would you say something like that it's fine but you know i i like it when you're not here either because that means that you're doing a good job so let's see about like getting your knee fixed up but i want to talk about some of the other issues that you have first so we know that you have hypertension right and i discussed maybe you getting a blood pressure cuff because i needed you to measure those a bit more regularly did you get the cuff [patient] what no [doctor] no okay that's fine have you measured your blood pressure recently at all [patient] no [doctor] okay are you still taking your medication because i see you're on twenty milligrams of lisinopril [patient] yeah most days i remember [doctor] okay [patient] ra i'm not suspicious but we're just gon na go with that okay because looking at your vitals it it is of still a bit high i'm not really comfortable i see like a hundred and eighty over you know eighty and [doctor] that's not where we wan na be so i wonder if we might need to adjust your medication but let's talk about your diabetes how are your blood sugars [patient] i think they're little bit better [doctor] okay what makes you think that have you been taking them [patient] yeah i check it you know most days again kinda when i remember [doctor] okay how often are you checking it [patient] i would say four five times a week [doctor] okay you might wan na switch to maybe two or three times a day but you know that's something i'm glad that you are measuring are you taking your metformin [patient] yes [doctor] okay and then i think we have you on five hundred milligrams correct [patient] yes [doctor] alright how is your diet [patient] kinda the same as my exercise decent could be better [doctor] alright and okay not a problem so what is your do you are you measuring your calories at all looking at your macros are you just eating what you feel like [patient] yeah just trying to watch what i eat more than anything but nothing specific [doctor] okay and are you do you know if you're particularly focused on your salt like is it like a low salt diet [patient] no just trying to watch my carbs a little bit more but not counting or anything [doctor] alright so like is it a specific diet i just wan na make sure like are you on like the keto diet [patient] no [doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally i would like to look at your knee though so when i press here on the outside does it hurt [patient] little bit [doctor] okay and then when i press on the inside does it hurt [patient] no [doctor] alright can you bend your knee and straighten it [patient] i can i think that's all i can i can bend [doctor] mm-hmm alright so are you having problems walking can you bear weight [patient] i can but i have a little bit of a limp [doctor] okay so do you mind getting up and walking for me really quickly alright so i do notice that there is a slight gait like there is a small sorry you are correcting you do have a limp i i am a little worried about that but it's probably it's probably the superficial when i'm looking at your knee i do notice some like ecchymosis and edema that just means bruising and swelling along the lateral aspect of your knee i do n't notice any effusion and it looks like you have a decent range of motion but i do understand that you know you are experiencing pain with some movement okay i'm gon na go ahead and order an x-ray and when you come back we can have that discussion alright so i reviewed the results of your right knee x-ray which showed no evidence of fracture or bony abnormality so let's talk about my assessment and plan alright so for your first problem of right knee pain i think you have a lateral a lateral ligament strain i wan na prescribe some meloxicam which is gon na be fifteen milligrams daily for pain and swelling i'm gon na refer you to physical therapy to help strengthen the muscles around the area and to prevent further injury if you're still having pain we can do further imaging imaging but like this is a common injury that tends to heal on its own for your second problem with hypertension i wan na continue the lisinopril at twenty milligrams and order an echo i am concerned that we might not be getting your blood pressure to where we need it to be so we might have to do some medication modification for your third problem with diabetes i wan na order an a1c i know that you said you have been measuring your blood sugars but i think this would give us a better image of what's been happening long term and i also wan na order a lipid panel in case we need to make any adjustments to that medication as well do you have any questions [patient] sounds good [doctor] alright awesome

ASSESSMENT

1. Right knee pain, lateral ligament strain.
 2. Hypertension.
 3. Diabetes type 2.

PLAN

After reviewing the patient's examination and radiographic findings today, his symptoms appear to be consistent with a lateral ligament strain of the right knee. I am going to prescribe meloxicam 15 mg once daily for pain and swelling. I also put in a referral for physical therapy so he can work on strengthening the muscles around the area and prevent any further injury. We can consider further imaging if he continues to have pain, but I explained that this is a common injury that typically heals on it's own.

 For his hypertension, I'm concerned that his blood pressure is not well controlled at this time, so we may need to modify his medication. I'm going to order an echocardiogram for further evaluation, but I want him to continue taking his lisinopril 20 mg for now.

 For his diabetes, he stated that he has been measuring his blood glucose levels 4 to 5 times per week, but I want him to start measuring them 2 to 3 times per day. His hemoglobin A1c levels should provide more detail as far as his long-term progress so we will order that today. I'm also going to order a lipid panel and we can determine if any adjustments need to be made to his medication. In the meantime, he should continue taking metformin 500 mg.
 "


[doctor] alright so hey it's nice to see you jack i know you've been experiencing some neck pain could you tell me what happened [patient] yeah so i was in a a car accident [doctor] mm-hmm [patient] and i hit in the back and like my my neck went forward and my head went forward really quick and so i've been having some pain ever since [doctor] okay and so with this pain how long ago was the car accident [patient] that was about a week ago [doctor] okay with this pain like on a scale of one to ten how severe is it [patient] i would say it's about a seven [doctor] okay [patient] it's not a constant pain but like whenever i move my head which is like a lot i i feel it [doctor] alright so where exactly is it on the side on the back [patient] it's in the back of my neck [doctor] okay has anything made it better [patient] i mean i've tried some ibuprofen that helped a little bit but not too much [doctor] mm-hmm [patient] just about five out of ten [doctor] mm-hmm alright and did you say whether the pain was getting worse [patient] i mean it's been staying the same it just gets worse when i'm moving my neck [doctor] okay are you able to turn your neck from side to side [patient] mostly but there is there is pain with it [doctor] okay and then do you have headaches [patient] yeah i had i had a couple early on [doctor] uh uh [patient] i have had it lately [doctor] okay and so does the pain move anywhere like your upper back your shoulder [patient] no it just stays on monday [doctor] okay and then any kind of hearing any kind of hearing problems visual disturbances [patient] no [doctor] okay have you do have you ever like played sports before or had like a sports accident before [patient] yeah i played football [doctor] okay [patient] years ago but i i did n't have any issues with my neck though [doctor] okay and then when you got in the car accident did you end up going to the emergency room [patient] no i mean i i know that going to the emergency room that like the english rides like five hundred bucks so i did n't want to do that [doctor] i understand i understand okay was there any like swelling or bruising on your neck [patient] not that i know about no other mag of my neck i really ca n't see that [doctor] yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt [patient] yeah a little bit [doctor] okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders [patient] no that's fine [doctor] okay so when you flex your neck when you're touching your chin to your chest does that hurt [patient] mm-hmm [doctor] alright positive pain with flexion what about when you move it back [patient] yeah that hurts worse [doctor] okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt [patient] yeah a little bit [doctor] okay positive pain with rotation and then can you touch your ear to your shoulders [patient] no [doctor] okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe what you have is something called neck strain for your neck pain i sorry treatments we are gon na go ahead and treat this a bit conservatively your i'm gon na put you on anti-inflammatories motrin six hundred milligrams and you're gon na take that every six to eight hours i also wan na give you a muscle relaxant called flexeril and it's gon na be ten milligrams and you'll take that every twelve hours as needed i'm gon na want you to try your best to to like relax your neck i'm sorry not to strain your neck anymore like to be conservative with how you move about and everything like that i also wan na order an mri just because you said you did n't go to the hospital or anything like that i just wan na make sure that you you're not suffering from like a concussion but this is something that's commonly referred to as like whiplash right your head just like it it just wiped essentially like back and forth to so severely and and that's probably what's causing your pain i think i wan na refer you to either physical rehab or a chiropractor once we get the results of the mri just to make sure that there is n't any impingement of like the nerves or anything like that do you have any questions [patient] i heard the chiropractors will shake they work [doctor] i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like that rehab and physical therapy [patient] okay [doctor] alright any other questions [patient] no [doctor] alright thank you

ASSESSMENT

Neck strain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed his x-rays did not reveal any signs of a fracture or bony abnormalities. Treatment options were discussed and conservative treatment has been recommended. He will begin taking Motrin 600 mg every 6 to 8 hours. A prescription for Flexeril 10 mg every 12 hours as needed was also provided. He was advised to be mindful of how he moves his neck and to be conservative to avoid straining his neck. I have also recommended that we obtain an MRI for further evaluation as the patient did not go to the emergency room following his accident. He will also be referred to either physical rehab or a chiropractor pending his MRI results.
 "


[doctor] hey lawrence how're you doing [patient] i'm doing alright aside from this elbow pain [doctor] so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain [patient] so i really during this pandemic i really got into ceramics and doing pottery so i've been doing a lot of pottery and over the past week i then started to develop this elbow pain [doctor] okay and then so tell me a little bit more about that elbow pain where does it hurt exactly [patient] you know it hurts a lot in the inside of my elbow [doctor] okay so the inside of your right elbow okay [patient] yeah [doctor] and then does the pain radiate down your arm or up into your shoulder or anything like that [patient] it does n't go into my shoulder it's it stays mostly at my elbow but it can go down a bit into my forearm [doctor] okay and then do you remember any trauma did you hit your arm or elbow or any on anything [patient] no nothing i i really was trying to think if there is anything else and i ca n't think of anything [doctor] okay and you've never injured that right elbow before [patient] no [doctor] alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life [patient] i would say probably a six [doctor] okay and does that pain keep you up at night [patient] it does [doctor] okay and when you have that kind of pain does it keep you from doing other type of activities [patient] yeah i mean i still try to like work through with using my arm but yeah it's it's it's difficult for me sometimes to lift and do things because of that pain [doctor] okay and then and how long has this pain been going on [patient] about four days now [doctor] alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief [patient] i've tried ibuprofen that helps a little but not much [doctor] okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here [patient] yes i do [doctor] okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that [patient] not really [doctor] okay now turn your wrist in so do you have any pain when you do that [patient] yeah that hurts [doctor] okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist [patient] yes i do [doctor] alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend [doctor] that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay [patient] alrighty [doctor] alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week [patient] alright thank you [doctor] thank you

ASSESSMENT

Right medial epicondylitis.

PLAN

The patient and I discussed his diagnosis in detail, and I explained that his symptoms are likely caused by overuse and potential damage of the tendons. We will provide him with sling to be worn during the day while he is awake. I want him to take ibuprofen 600 mg every 6 hours with food for a full week and ice the elbow for 20 minutes, 3 times daily. Finally, I advised the patient to rest his elbow and avoid doing any pottery for the next couple of weeks.


[doctor] hey jean how're you doing today [patient] i'm doing alright aside from this foot pain that i have [doctor] so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened [patient] yeah so yeah i was playing in a soccer game yesterday and i was trying to steal the ball from another player and she ended up falling directly onto my right foot and i do n't know i i mean i was trying to get around her and my body ended up twisting around her and then i accidentally felt a pain in my foot [doctor] okay so have you ever hurt your left foot before [patient] no i've had a lot of injuries in soccer but never injured this foot [doctor] okay and then so after the fall and the entanglement with the other player were you able to continue playing [patient] no i had to stop playing right away and actually being helped off the field [doctor] wow okay and what have you been doing for the the pain since then [patient] so i've been keeping it elevated icing it the trainer wrapped it yesterday and taking ibuprofen as well [doctor] okay alright so without any ibuprofen can you tell me what your pain level is [patient] without ibuprofen i would say my pain is a three [doctor] okay and then with your ibuprofen can you tell me what your pain level is [patient] like a seven eight [doctor] okay so how long have you been playing soccer [patient] really since i was like four five i've been playing a long time [doctor] well that's cool yeah we our our youngest daughter she is almost sixteen and she plays the inner marrial soccer league they are down at the rex center did is that where you started playing or did you guys did you start playing somewhere else [patient] yeah just like this local town leak i started playing that way and then played all throughout school [doctor] that's [patient] high school teams [doctor] that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation [patient] no i have not [doctor] okay now if it's okay with you i would like to do a quick physical exam i reviewed your vitals and everything looks good blood pressure was one eighteen over seventy two heart rate was fifty eight respiratory rate was fourteen you are afebrile and you had an o2 saturation of ninety nine percent on room air on your heart exam your regular of rate and rhythm do n't appreciate any clicks rubs or murmurs no ectopic beats noted there on auscultation listening to your lungs lungs are clear and equal bilaterally so you're moving good air i'd like to do a focused foot exam on your left foot so i do see some bruising on the bottom of your foot and on the top of your foot as well now there is associated swelling and i do appreciate tenderness to palpation of your midfoot and you are positive for the piano key test on a neurovascular exam of your left foot you have a brisk capillary refill of less than three seconds dorsalis pedis pulse is intact and strong and you do have motor and sensation that it's intact to light touch now i would like to do a review of the diagnostic imaging that you had before you came in so i do notice a 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 so lem me talk to you a little bit about my assessment and plan now for for the first concern of right foot pain your right foot pain is due to a lisfranc fracture which is a fracture to one of your second metatarsal bones at the top of your foot where the metatarsals meet your cuboids now there are ligaments at the top of your foot so i'm gon na be ordering an mri to assess for injury to any of these ligaments now based on your exam and from what i'm seeing on your x-ray you're most likely going to need surgery of that foot now the surgery will place the bones back in their proper position and using plates and screws will hold them there while they heal and this is gon na allow those bones and ligaments to heal properly it is a day surgery and you will be able to go home the same day and then i'm going to have you follow up with me here in the clinic you'll be in a cast and you will need to use crutches and you will not be able to use that left foot for about six to eight weeks now after that six to eight weeks you will gradually start walking on your foot based on how you tolerate it and we'll see how you do at that point so i do believe you're gon na need surgery i i'm recommending this because there are significant complications to your foot if we do not do this poor bone and ligament healing can lead to losing the arch of your foot and you're becoming flat-footed you also have a high likelihood of developing arthritis in that foot so what i'm gon na do unfortunately you'll be out the rest of the season but we are gon na get you fixed up and ready for next season if you're okay with all of this i'm gon na have the nurse come in and get you started on your paperwork and then i will see you on monday morning and we will get your foot taken care of [patient] alright thank you [doctor] you're welcome

ASSESSMENT

Lisfranc fracture, left foot.

PLAN

I explained the nature of her injury in detail. Based on her exam and x-ray findings, she will most likely require surgery of the left foot, but I want to order an MRI to assess for any ligamentous injuries. We discussed the procedure and postoperative expectations, such as recovery time and restrictions, at length. We also discussed the complications associated with deferring surgical intervention including poor bone and ligament healing, pes planus deformation, and a high likelihood of developing arthritis in the foot. She will be unable to participate for the remainder of the soccer season, but should be able to play next season.


[doctor] patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable . [doctor] worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . the mri reveals a pituitary lesion with elevation and compression of the optic chiasm . the ventricles are normal in size and no other abnormalities are lo- are noted . [doctor] hello , mr . ward . nice to meet you . i'm dr. flores . [patient] hi , doc . nice to meet you . [doctor] i was just reviewing your records from dr. howard and he's referred you because the workup for headaches revealed a mass on your pituitary gland . i did review your mri images and you have a significant mass there . can you tell me about the issues you've been experiencing ? [patient] yeah sure . so i'm really getting fed up with these headaches . i've been trying my best to deal with them but they've been going on for months now and i'm really struggling . [doctor] where are the headaches located and how would you describe that pain ? [patient] located behind my eyes . it's like a dull nagging ache . [doctor] okay . was the onset gradual or sudden ? [patient] well it started about three months ago . and they've been getting worse over time . at first it was like three out of 10 severity , and it just gradually worsened . and now it's about six out of 10 severity . the headaches do tend to be worse in the morning and it feels like a dull ache behind the eyes . they last a few hours at a time , nothing makes them better or worse . [doctor] okay . can you tell me if the pain radiates , or if you have any other symptoms ? specifically feeling sick , fever , rashes , neck stiffness , numbness , weakness , passing out ? [patient] no . i have n't been sick or felt sick . ca n't recall a fever or any kind of rash . no- no neck issues , no numbness , no tingling . and i've never passed out in my life . but , um , for some reason recently i seem to be bumping into door frames . [doctor] okay . have you noticed any change in your vision or with your balance ? [patient] no i do n't think so . my eyes were checked in the fall . [doctor] okay . let's see , do you have any other medical problems that you take medicine for ? [patient] no i do n't have any medical problems and i do n't take any medicines . i tried tylenol a few times for the headaches but it did n't work , so i stopped . [doctor] i see . anyone in your family have any history of diseases ? [patient] i was adopted so i really have no idea . [doctor] okay . um , what kind of work do you do ? and are you married ? [patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house . [doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ? [patient] nope . i do n't do any of those and never have . [doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done . [patient] sounds good , doc . [doctor] all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . visual field testing reveals bitemporal hemianopia . and color vision is normal . [doctor] all right , mr. ward . i'm going to review these pictures from the mri with you . um , now this appears to be a benign pituitary adenoma , but there's no way to be sure without sending the removed adenoma to pathology to make the diagnosis , which we will do . um , here you can see it's a well defined mass . and it's pressing right here on what we call the optic chiasm . and today when i was having you look at my fingers , you could n't see them off to the sides , that's what we call bitemporal hemianopia . and explains why you have been bumping into door frames . [patient] yeah i never noticed that i could n't see out of the side until you did that test , and you closed one eye with both eyes . i really could n't tell . [doctor] no because you're having this vision loss from the mass compressing the optic chiasm , the only option we have is to do surgery . [patient] okay , i understand . do you think i'll regain my vision ? [doctor] well there's no guarantees , but it is a possibility . i'm gon na refer you to the eye doctor for a full exam and they'll do what's called visual field test . this will map our your peripheral vision or side vision prior to surgery . and we can monitor after surgery to see if your vision is improving . [patient] all right . [doctor] and let's discuss the surgery a little more . um , we would do what's called a transsphenoidal approach to do the surgery . this is minimally invasive and we go through the sphenoid sinus . there are some risks i have to inform you of . uh , risk of anesthesia including but not limited to the risk of heart attack , stroke , and death . risk of surgery include infection , need for further surgery , wound issues such as spinal fluid leak or infection , uh , which may require long , prolonged hospitalization or additional procedure . uh , seizure , stroke , permanent numbness , weakness , difficulty speaking , or even death . [patient] well i guess we have to do it regardless . [doctor] okay . so i will have you see our surgery scheduler , deborah , on the way out to get you set up . we will get this scheduled fairly quickly so i do n't want you to be alarmed . um , she'll also get you set up today or tomorrow to have the visual field test and you may not be able to see the eye doctor until after surgery . but we have the pre-surgery visual field test for comparison after surgery . [patient] okay . i look forward to these headaches going away . i never thought it could be something like this going on . [doctor] yeah . come this way , we'll get your things lined up . please call if you think of any questions . [patient] thanks , doctor . [doctor] diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note .

ASSESSMENT

• Pituitary adenoma
 • Bitemporal hemianopia

 Mr. Ward is a very pleasant 52-year-old male who has a benign appearing pituitary adenoma discovered on work up for worsening headaches. There is clinical and radiographical evidence of optic chiasmal compression, examination today revealed a bitemporal hemianopia. Radiographically this appears to be a benign pituitary adenoma but that there was no way to be sure without a pathological diagnosis. Surgical intervention to excise and decompress the pituitary fossa is indicated given optic chiasmal compression.

PLAN

Pituitary adenoma.
 We discussed the general indications for surgical intervention. The risks, benefits to trans-sphenoidal resection were explained to the patient. The risks of anesthesia including but not limited to the risks of heart attack, stroke, and death. The risks of surgery including infection, need for further surgery, wound issues (such as spinal fluid leak or infection) which may require prolonged hospitalization or additional procedure, seizure, stroke, permanent numbness, weakness, difficulty speaking, or death. The patient voiced understanding and wishes to proceed with trans-sphenoidal resection of the adenoma.

 Bitemporal hemianopia.
 We will have the patient scheduled this week to have visual field testing with ophthalmology. The preoperative visual field will serve as baseline for comparison of postoperative visual field testing to monitor for improvement in the bitemporal hemianopia. Additionally, we discussed that unfortunately no guarantees could be given that his vision would return.


[doctor] hi , brian . how are you ? [patient] hi , good to see you . [doctor] it's good to see you too . so , i know the nurse told you a little bit about dax . [patient] mm-hmm . [doctor] i'd like to tell dax about you , okay ? [patient] sure . [doctor] so , brian is a 58 year old male with a past medical history significant for congestive heart failure and hypertension , who presents today for follow-up of his chronic problems . so , brian , it's been a little while i've seen you . [patient] mm-hmm . [doctor] whats , what's going on ? [patient] i , i just feel out of sorts lately . i do n't know if it's the change in the seasons or if we're just doing a lot of projects around the house and , and some , some construction on our own . i'm just feeling out of it . lack of , uh , energy . i'm just so tired and fatigued , and i feel kinda ... i feel lightheaded every once in a while . [doctor] okay . all right . um , how long has that been going on for ? [patient] uh , probably since labor day , so about five weeks or so . [doctor] okay . and , have you noticed any , like , symptoms of weight gain , like , like swollen legs , or , you know , your belly feels bloated and things like that ? [patient] i feel , i feel bloated every once in a while . [doctor] okay . all right . um , and , are you taking your , your medications ? [patient] uh , yes , i am . [doctor] okay . and , how about your diet ? are you watching your diet ? [patient] uh , it's been a little bit of a struggle . we began construction on our kitchen over labor day weekend , and it was ... hard to cook or prepare meals so we ate out a lot, and not always the best food out. it , it , it kind of reeked havoc , uh , so it's been maybe off a little bit . [doctor] okay . all right . and , how about , you know , other symptoms , like , have you had a fever or chills ? [patient] no . [doctor] okay , and any problems breathing ? do you feel short of breath ? [patient] uh , just when i'm doing doing the projects . again , not even lifting anything really heavy , it's just that if i'm ex- exerting any energy , i , i kinda feel it at that point . [doctor] okay . do you have any chest pain ? [patient] slight cramps . that seems to go away after about , maybe about an hour or so after i first feel it . [doctor] okay , and how about a cough ? [patient] a , a slight cough , and again , i'm not sure if it's just the change of seasons and i'm getting a cold . [doctor] mm-hmm . okay . all right . well , you know , for the most part , how , you know , before all of this- [patient] mm-hmm . [doctor] . how were you doing with your heart failure ? i know that we've kinda talked about you being able to watch your healthy food intake and that's been kind of a struggle in the past . [patient] i , i , i've actually been pretty good about that ever since . the , the , the last year , it's been a little chaotic , but i wanted to make sure i stayed on top of that . [doctor] okay . all right . are you excited for halloween ? [patient] uh , ca n't wait . [doctor] okay . [patient] our home renovations should be complete by then [doctor] all right , yeah , right . [patient] yeah . [doctor] and , so , lastly , for your high blood pressure , how are you doing with that ? have , are , did you buy the blood pressure cuff like i asked ? [patient] yeah , i , i did , and we do mon- , i , i monitor it regularly . my wife makes sure i stay on top of that , but it's been pretty good . [doctor] okay . all right . well , i know you did the review of systems sheet when you checked in , and you were endorsing this fatigue- [patient] mm-hmm . [doctor] . and a little dizziness and we just talked a lot about a lot of other symptoms . [patient] mm-hmm . [doctor] any other symptoms i might be missing ? nausea or vomiting , diarrhea ? [patient] no . [doctor] anything like that ? [patient] no . [doctor] okay . all right . well , i just want to go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey , dragon ? show me the vital signs . so , looking at your vital signs here in the office , everything looks good . you know , your blood pressure and your heart rate and your oxygenation all look really good . [patient] mm-hmm . [doctor] so , i'm gon na just take a listen to a few things and check some things out , and i'll let you know what i find , okay ? [patient] perfect . [doctor] okay . so , on your physical examination , you know , i do appreciate some jugular venous distention to- [patient] mm-hmm . [doctor] to about eight centimeters . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which we've heard in the past . and , on your lung exam , i do appreciate some fine crackles at the bases bilaterally , and your lower extremities have , you know , 1+ pitting edema . so , what does all that mean ? that means i think you're retaining a little bit of fluid . [patient] mm-hmm . [doctor] okay ? i wan na just go ahead and look at some of your results , okay ? [patient] sure . [doctor] hey , dragon ? show me the chest x-ray . so , looking here at the results of your chest x-ray , it does look like you have a little bit of fluid in your lungs there , and that can be just from , um , your heart failure , okay ? hey , dragon ? show me the echocardiogram . so , this is the echocardiogram that we did about four months ago , and this shows that the pumping function of your heart is a little bit reduced at 45 % , and it also shows that leaky valve , the mitral regurgitation that , that you have , okay ? um , so , let me just go over and talk about , a little bit , my assessment and my plan for you . [patient] mm-hmm . [doctor] okay ? so , for your first problem , your congestive heart failure , i think you're retaining fluid , and i wan na go ahead and increase your lasix to 80 mg once a day . [patient] mm-hmm . [doctor] i want you to weigh yourself every day . i want you to call me if you're gaining more weight . [patient] mm-hmm . [doctor] and , i certainly want you to call me if you have any other symptoms of shortness of breath , and i wan na go ahead and order another echocardiogram , okay ? [patient] sure . [doctor] hey , dragon ? order an echocardiogram . lastly , for your high blood pressure , it looks like you're managing it well at this time , okay ? so , i wan na go ahead and continue with the lisinopril 20 mg a day . i want you to continue to record your blood pressures at home , and report them to me in the patient portal if you see they're getting elevated , okay ? [patient] mm-hmm . [doctor] does that sound like a plan ? [patient] that sounds fine . [doctor] okay . um , i'm gon na be in touch with you after we get your test results , and we'll go from there , okay ? [patient] sure . [doctor] all right . hey , dragon , finalize the note .

ASSESSMENT AND PLAN

Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow up of his chronic problems.

 Congestive heart failure.
 • Medical Reasoning: The patient reports increased fatigue, dizziness, and chest discomfort on exertion. He also exhibits some jugular venous distention, lung base crackles, and lower extremity edema on exam today. He has been compliant with his current medications but admits to dietary indiscretion lately. His recent echocardiogram demonstrated a reduced ejection fraction of 45%, as well as mitral regurgitation.
 • Additional Testing: We will order a repeat echocardiogram.
 • Medical Treatment: Increase Lasix to 80 mg daily.
 • Patient Education and Counseling: I advised the patient to monitor and record his daily weight and report those to me via the patient portal. He will contact me should he continue to experience any dyspnea.

 Hypertension.
 • Medical Reasoning: This is well controlled based on home monitoring.
 • Medical Treatment: Continue lisinopril 20 mg daily.
 • Patient Education and Counseling: I advised him to monitor and record his blood pressures at home and report these to me via the patient portal.


[doctor] hi , edward , how are you ? [patient] i'm doing well , yourself ? [doctor] i'm doing okay . [patient] good . [doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you . [patient] absolutely . [doctor] edward is a 59 year old male with a past medical history significant for depression , hypertension and prior rotator cuff repair who presents for followup of his chronic problems . so , edward , it's been a little while since i saw you . [patient] mm-hmm . [doctor] how are you doing ? [patient] i'm doing pretty well , actually . it's been a good , uh , good six months . [doctor] good . okay . so , you know , the last time we spoke , you know , you were trying to think of some new strategies to manage your depression . you did n't wan na go on medication because you're already on a bunch of meds . [patient] absolutely . [doctor] so , how are you doing with that ? [patient] i'm doing well . i see a counselor , uh , once a week . uh , and i've been out swimming at the pool a lot this , this , uh , summer , and , uh , fall . so , things have been well , going well with my depression . [doctor] okay , so , you do n't wan na , you do n't feel the need to start any medications at this time ? [patient] no , no , no . but , i know i can call you if i do . [doctor] yeah , absolutely . [patient] okay . [doctor] yeah . all right . and then , in terms of your high blood pressure , how are you doing with that ? i know we , we were kind of struggling with it la- six months ago . how are you doing ? [patient] i still have my good days and my bad days . i do take my medicine daily . uh , but , you know that burger and wine , every once in a while , sneaks in there , and that salt be ... we know what that does . [doctor] yeah . so , i love burgers and wine too . [patient] okay . [doctor] so , i get it . um , okay , so , and you're taking the norvasc ? [patient] norvasc , yep . [doctor] okay . um , and , you're checking your blood pressures at home , it sounds like ? [patient] i , i do . well , i go to cvs pharmacy . they , they have a , uh , machine that i can sit down at quickly and get my , uh , blood pressure taken . and , i go there about once a week . [doctor] okay . all right . and then , i know that you had that rotator cuff repaired about eight months ago . how are you doing ? [patient] um , it's doing well . i , i'm , i'm , been stretching with a yoga ball . [doctor] uh- . [patient] and , uh , i'm getting stronger each time . and , i can continue that once a week also . [doctor] okay . are you still seeing the physical therapist in the center , or are you just doing exercises at home ? [patient] i'm just , i progressed to exercises at home . [doctor] okay . all right . great . all right . well , i know you did a review of systems sheet when you checked in . [patient] mm-hmm . [doctor] and , you know , it seems like you're doing well . any symptoms at all ? any nasal congestion or chest pain , shortness of breath , anything ? [patient] no . none of those . i do , do notice that i get a little bit of a de- , uh , swelling in my ankles . [doctor] okay . [patient] uh , mainly near the end of the day . [doctor] okay . [patient] um , it seems to go away by the next morning . [doctor] okay . all right . all right . maybe that has to do with some of the salt intake you're , you're eating . [patient] okay . [doctor] all right . well , i wan na go ahead and do a quick physical exam , okay ? [patient] mm-hmm . [doctor] hey , dragon ? show me the blood pressure . yeah , so , your blood pressure's a little elevated today , 156 over 94 . [patient] okay . [doctor] you know , you could be a little happy to see me . i do n't know .  [doctor] um , but let's look at some of the readings . hey , dragon ? show me the blood pressure readings . yeah , so , they've been a , running a little high over the past couple months . [patient] okay . [doctor] so , we'll have to just kinda talk about that , okay ? [patient] okay . [doctor] i'm gon na go ahead and listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] okay . [doctor] okay . all right . so , on physical exam , you know , everything looks good . on your heart exam , i do appreciate a slight three out of six systolic ejection murmur , but we've heard that in the past . [patient] okay . [doctor] so , that seems stable to me . um , on your lung exam , everything sounds nice and clear , and on your lower extremity exam , i do appreciate , you know , 1 to 2+ pitting edema in your legs , okay ? so , we'll have to just talk a little bit about your diet and decreasing the salt intake , okay ? [patient] okay . [doctor] so , let me just look at some of your results , okay ? hey , dragon ? show me the labs . so , looking here at your lab results , everything looks really good . you know , your creatinine , that's your kidney function , that looks stable . everything looks good from that standpoint . hey , dragon ? show me the ekg . and , looking here at your ekg , everything , you know , looks fine . there's no evidence of any coronary artery disease . it's a nice , normal ekg , which is good . [patient] okay . [doctor] okay ? [patient] good . [doctor] so , let me just talk a little bit about my assessment and my plan for you . okay ? so , from a depression standpoint , it's , you know , your first problem , i think that that sounds like you're doing really well managing it . you know , you have good strategies . it sounds like you have a good support system , um , and i agree . i do n't think you need to start on any medication at this time , but you said before , you know you can call me , okay ? [patient] yes . [doctor] for your second problem , your hypertension , i , i do n't believe it's well controlled at this time . so , i wan na go ahead and , you know , increase the norvasc up to 10 mg a day , and i wan na go ahead and order an echocardiogram and a lipid panel , okay ? [patient] okay . [doctor] hey , dragon ? order an echocardiogram . and , for your third problem , your rotator cuff repair , i , i think you're doing really well with that . i would just continue with the exercises and , uh , i do n't think we need to intervene upon that anymore . it sounds like that's pretty much resolved , okay ? [patient] good . good . [doctor] do you have any questions about anything ? [patient] no questions . [doctor] okay , great . hey , dragon ? finalize the note .

ASSESSMENT AND PLAN

Edward Butler is a 59-year-old male with a past medical history significant for depression, hypertension, and prior rotator cuff repair. He presents for a follow-up of his chronic problems.

 Depression.
 • Medical Reasoning: He is doing well with therapy and physical activity. He continues to decline medication for this.
 • Medical Treatment: Continue current management strategies.
 • Patient Education and Counseling: I encouraged him to contact me should he want to try medication.

 Hypertension.
 • Medical Reasoning: This is uncontrolled at this time. He is compliant with Norvasc, but admits to occasional dietary indiscretion.
 • Additional Testing: We will order a lipid panel and an echocardiogram.
 • Medical Treatment: Increase Norvasc to 10 mg daily.

 8 months status post rotator cuff repair.
 • Medical Reasoning: He is doing well postoperatively. He has progressed from formal physical therapy to solely home exercise.
 • Medical Treatment: Continue with home exercise.


[doctor] karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you [patient] i'm okay i guess [doctor] hey dad how are you doing [patient] hey doc i am okay yeah karen has been having this eye twitch i noticed a couple of weeks ago when i talked to her pediatrician and they told me to come see you [doctor] okay alright so karen have you felt the twitch [patient] yeah well i mean i feel my face sometimes [doctor] yeah and do you have any pain when it happens [patient] no it it does n't really hurt but i noticed that dad looks real nervous when it happens [doctor] yeah i i i can understand that's because he loves you do you feel the urge to move your face [patient] sometimes and then it moves and then i feel better [doctor] okay okay and so so dad how often are you seeing the twitch on karen [patient] i do n't know i mean it varies sometimes i see it several times an hour and there is other days we do n't see it at all until sometimes late afternoon but we definitely notice it you know everyday for the last several weeks [doctor] okay so karen how is how is how is soccer [patient] i like soccer [doctor] yeah [patient] yeah dad dad takes me to play every saturday [doctor] okay [patient] it's it's pretty fun but there's this girl named isabella she she plays rough [doctor] does she [patient] she yeah she tries to kick me and she pulls my hair and [doctor] oh [patient] sometimes she's not very nice [doctor] that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson [patient] yeah and and then sometimes after soccer we we go and i get mcdugge's and it and it's it makes for a nice day with dad [doctor] is that your favorite at mcdonald's in the the mcnuggates [patient] not not really but they are cheap so [doctor] okay alright well you you made dad happy at least right [patient] yeah that's what he says because i'm expensive because i want dresses and dogs and stuff all the time [doctor] yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens [patient] no i mean when it happens she just continues playing or doing whatever she was doing when it happens [doctor] okay alright has she has she otherwise been feeling okay since this started has she been acting normally [patient] i i'd say she seems fine i mean she has been eating well and playing with her friends and she goes about her normal activities really [doctor] okay good [patient] never even though anything was going on [doctor] okay alright good so has has karen had any seizures in the past [patient] no [doctor] no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching [patient] well no uh it's just her face [doctor] okay [patient] i mean the whole side of her face moves when it happens it seems like it several seconds and then it finally stops and she just seems to be blinking frequently and and and you know wait a minute i i did make a video so you can see just in case it does n't do it during the visit [doctor] okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome [patient] well no history of seizures but i i i never heard of that tourette thing [doctor] yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger [patient] really i had nobody in our family got anything like that [doctor] okay now tell me have you noticed any other symptoms how about like fever or chills [patient] no [doctor] okay coughing headache [patient] ma'am [doctor] okay how about any problems with karen's sleep [patient] nope [doctor] okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay [patient] okay [doctor] alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there [patient] mm-hmm [doctor] does that feel the same [patient] yeah [doctor] okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator drift sensation is intact reflexes are two plus and symmetric at the biceps triceps knees and ankles so this means everything looks good karen [patient] that's great [doctor] good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school years and tics can also include things like shoulder shrugging facial grimacing sniffling excessive throat clearing and uncontrolled vocalization i can say that essentially they're brief sudden and involuntary motor movements now we do n't have a full understanding of the cause of the tics but they typically occur around five to ten years of age but most ticks go away on their own and they disappear within a year so these are what we call transient tics and the best thing to do is ignore the tics so it does n't seem to be bothering karen and she seems to be doing well in school and activities so it may wax and wane over time but you might notice it more towards the end of the day when the child is tired so you may also you know see it if they're stressed so that's why it's important to just ignore it now when you draw attention to the tick it does make the child conscious so that can make the tic worse so we want to be careful again just to to kind of not to draw too much attention on it and do you have any questions for me [patient] so you mean you're telling me you do n't think he had a seizure or a bit or nothing [doctor] yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards [patient] so you're not recommending any kind of treatment there is no pill or cream or nothing [doctor] not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay [patient] alright alright sounds good [doctor] alright thank you you guys have a good day [patient] doctor [doctor] bye karen

ASSESSMENT AND PLAN

1. Transient tics.
 - Medical Reasoning: The patient's father provided a video today as she did not have a twitch in office. It appears the patient is experiencing a tic.
 - Patient Education and Counseling: Nature of the diagnosis was discussed today with the patient and her father. I advised eye tics are very common in children and as many as 1 in 5 children have a tick during their school years. We discussed tics can also include things like shoulder shrugging, facial grimacing, sniffling, excessive throat clearing, and uncontrolled vocalization. I explained that essentially they are brief, sudden and involuntary motor movements and that we do not have a full understanding of the cause. We also discussed that they typically occur around 5 to 10 years of age and mostly resolve on their own within a year. Dad was advised that treatment is not recommended as they do not appear to be bothering Karen and she continues to do well in school and activities. Additionally, we discussed avoiding drawing attention to the tic as it may cause Karen to feel self-conscious and increase the severity of the tic.
 - Medical Treatment: None at this time.


[doctor] hey betty how are you doing [patient] i'm doing okay i just been really frustrated because with my asthma and it just seems like i can never catch a break never get better i'm always it seems like i'm always coughing and wheezing [doctor] i'm sorry to hear that what normally triggers your asthma type symptoms [patient] i find that it's really really when i get sick if i get sick with a cold i almost always know that my asthma is going to flare i did notice one time though that when i went to my aunt's house i i had a flare afterwards and i think it's because of her cat so i try to avoid going there and i have n't really had an issue since [doctor] okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems [patient] it seems like it happens really every month or every other month for the past six months i usually end up going to the urgent care a lot and get or my primary care doctor and so sometimes they'll give me antibiotics sometimes i'll get steroids one time it was so bad i actually ended up going to the emergency department [doctor] wow that that can be a little bit scary so you mentioned that your primary care provider or the urgent care provider gave you medications what medications are you using for your asthma right now [patient] i have two inhalers one but i really just use one of them it's a blue one that seems like the only inhaler that helps me the other one when i when i try to use it it does n't work [doctor] okay so do you think that's the albuterol inhaler is it do you remember the name like ventolin or [patient] yes yes that's the name of it [doctor] is that it okay alright and then how often do you feel like you need to use that [patient] i would say like almost everyday i feel like i'm using my inhaler because i'm always coughing and wheezing and a couple of times a night i'll wake up as a couple times a week i'll end up waking up needing to use my inhaler as well [doctor] okay and then when you use it at that time does it help [patient] it does [doctor] okay and how many walk me through how you use that you just wake up and you take one puff or is it two puffs [patient] yeah i take i usually take two puffs [doctor] okay but then you get enough relief that you can go back to sleep [patient] yeah for the most part [doctor] okay now have you ever needed to be hospitalized due to your asthma symptoms you mentioned you've had to go to the er [patient] yeah for only once i can think of when i was young i think like around eight years old i had to be hospitalized but nothing since then [doctor] okay i do wan na take a little bit of a a deeper dive here into your er and urgent care visits can you tell me a little bit more about those [patient] yeah i feel like i've had several i do n't remember the exact number but i've had several this past year they almost always have to start me on prednisone [doctor] okay like a prednisone taper pack that type of thing [patient] yeah yeah sometimes they'll just give me like like a like a large dose over five days [doctor] okay [patient] and then sometimes they make me take less and less and less so the over like nine or ten days [doctor] okay so both the dosepak and then also the high dose as well okay [patient] yeah [doctor] and then when was your last exacerbation [patient] probably about a month ago [doctor] okay so just out of curiosity you mentioned that you you have trouble when you go over to your aunt's house because of your cat now i see here that you really like to go outside and walk and do those type of things do you have any other type of issues whenever you you go outside any any seasonal allergies or anything like that [patient] no not really [doctor] okay so you do n't have any history of seasonal allergies which is good so it looks like here that you put down that you enjoyed hiking so you do n't have any trouble getting out and going hiking and and have you tried the new trails there behind behind the wreck center [patient] yeah i'm really excited to i mean i have to be careful because i you know with my coughing my wheezing but i'm really i'm looking forward to getting better so i can really start hiking again [doctor] okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis [patient] no i've never smoked and i do n't vape either or yeah i do n't smoke cigarettes or marijuana [doctor] okay and then you said you do n't vape so no vaping or e-cigarette use at all [patient] hmmm hmmm [doctor] okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that [patient] sometimes i go to the bars with some friends and yeah the smoking does irritate me [doctor] okay [patient] so i do n't try to go there often [doctor] okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam [patient] okay [doctor] now i reviewed your vitals for today and your your blood pressure is good it's one twenty eight over eighty two your respiratory rate is sixteen and your oxygen saturation is ninety nine percent on room air which is a good thing i'm gon na take a listen to your heart here your heart is regular rate and rhythm and i do n't appreciate any ectopic beats or and i do n't hear anything like rubs murmurs or gallops which is good so i'm gon na go take and listen to your lungs here on your lung exam i do appreciate some diminished lung sounds throughout with the occasional slight expiratory wheeze and that's bilaterally so i hear that on both sides i'm gon na go do a quick neck exam here neck is supple trachea is midline i do n't appreciate any lymphadenopathy taking a listen here i do n't appreciate any carotid bruit now i'm also gon na take a look at your hands here i note strong bilateral pulses i do n't appreciate any clubbing on any of your fingertips which is which is important and i also note brisk capillary refill i'm gon na go ahead and review the results of your pulmonary function test that i had you do when you came into the office today and reviewing those results i do see that they are consistent with somebody who would be diagnosed with asthma so lem me go ahead and tell you a little bit about my assessment and plan so now for your first problem of asthma your symptoms are consistent with moderate to intermediate or i'm sorry moderate moderate intermittent asthma and it's gon na be really important for us to be consistent with your inhaled inhaled steroid inhaler so i'm gon na need you to take that as prescribed and that's really gon na help cut down on those daily symptoms and needing to use that rescue inhaler that albuterol inhaler as frequently so the more you take and more consistently you take your inhaled steroid inhaler the less you will use your albuterol now it's not a fast acting inhaler like your albuterol but what is important is as going to be what helps you long term now if you do have an acute exacerbation so if you're having an acute issue with your breathing i do want you to continue to use your albuterol inhaler one to two puffs and then i want you to wait and see how your breathing is before you would take an additional one to two puffs we hope you have less of those acute exacerbations as you continue to use your inhaled steroid i'm also going to put together an asthma action plan for you and that's gon na help us look at your symptoms see where your your pain points can be you know like those being having issues with with cats or dust that type of thing and we'll work on how to handle those symptoms through that asthma action plan so do you have any questions comments or concerns otherwise i will see you in thirty days [patient] alright thank you [doctor] you're welcome [doctor] so let me tell you a little bit about my assessment and plan for your first problem of asthma your symptoms are consistent with moderate intermittent asthma i'm gon na start you on flovent one hundred ten micrograms one puff twice per day that's gon na be important for you to be consistent with your inhaled steroid inhaler this is gon na help prevent those daily symptoms and from needing for you to use your albuterol inhaler or that rescue inhaler less frequently you can continue using your ventolin inhaler and that would be two puffs every four to six hours p.r.n . i'm also gon na put together an asthma action plan for you so we know what to do based on your symptoms i'd like to see you again in a month or sooner if you have any worsening symptoms does that sound okay [patient] it does thank you [doctor] you're welcome i'll see you in a month [patient] alright thanks

ASSESSMENT AND PLAN

1. Moderate intermittent asthma.
 - Medical Reasoning: The patient's symptoms and results of her PFT are consistent with moderate intermittent asthma.
 - Patient Education and Counseling: I explained the importance of consistency with her daily inhaler as this will help prevent daily symptoms and the need to use the albuterol inhaler as frequently. My hope is that she has less acute exacerbations as she continues to use her inhaled steroid.
 - Medical Treatment: Prescribed provided for Flovent 110 mcg 1 puff twice per day. She can continue using her Ventolin inhaler 2 puffs every 4 to 6 hours as needed. I have recommended using her albuterol inhaler 1 to 2 puffs and then monitor her breathing prior to taking an additional 1 to 2 puffs. I am also going to put together an asthma action plan for her so we know what to do based on her symptoms.


[doctor] hi richard how are you the medical assistant told me that you have a tick bite is that what happened [patient] i really do n't know where i got it but i i had i do get out in the woods and i do spend a lot of time out in the yard but yeah i've got a tick bite around my knee and and it's been it's been over a week and and just it just burns and just quite annoying [doctor] okay and have you had any fever or chills [patient] i have not at this point it just feels warm on that spot [doctor] okay alright and have you noticed any other joint pain like in your elbows or shoulders or anything like that that since this started [patient] nothing other than my typical arthritic pain [doctor] okay alright now you say that you like to go outside and and you're working in the yard now i i heard that you were a a hunter when was the last time you went hunting has hunting season started yet i do n't even know [patient] well i i did go hunting not long ago couple of weeks ago [doctor] okay did you did you [patient] windle season is open well it it's actually on a on a a got the right word for it but it it's where they train dogs and things like that [doctor] okay [patient] type thing [doctor] okay did you i did did did were you able to shoot anything did you bring anything home [patient] well actually i yeah i shut several i had some grandchildren with me so i let them have what they wanted [doctor] nice nice you know i i did hear i do n't know much about hunting but i did hear a hunting software joke the other day do you want to hear it [patient] sure [doctor] so what software do hunters use for designing and hunting their pray [patient] man i have no idea [doctor] the adobee illustrator get it [patient] do n't be [doctor] anyway i die grass let's just get back to our visit here so about your line or about your tick bite so do you notice that it's hard for you to move your knee at all [patient] not at this time no [doctor] no and do you have any problems walking [patient] no [doctor] no okay and have you ever had a tick bite before [patient] i have when i was younger i used to get a lot of them because i spent a lot of time out of the woods never get into anesthesia takes you can get several bites out of that but this was just one [doctor] okay alright and have you ever been diagnosed with what we call lyme disease before [patient] i have not [doctor] you have not [patient] i would n't know so i would n't know what symptoms are [doctor] okay [patient] what you just asked me i guess maybe [doctor] yeah so some of those symptoms like any flu like symptoms have you had like any body aches or chills or anything like that [patient] no just really just kind of a a headache just generally do n't feel well [doctor] generally do n't feel well okay and has that been since the tick bite [patient] it has [doctor] it has okay alright and any other symptoms like a cough or shortness of breath or dizziness or anything like that [patient] no [doctor] okay now since you are here let me just ask you a little bit about your high blood pressure did you buy the blood pressure cuff i asked you to have you been checking your blood pressure at home [patient] periodically yes [doctor] okay and do you think that they are running okay [patient] yeah blood pressure seems to be doing okay the lisinopril works well [doctor] good i was just gon na ask you if you were taking your lisinopril so that's good okay and any side effects from the lisinopril since we started it i think we started it about a year ago two years ago [patient] no no no side effects that i'm aware of [doctor] no side effects okay and then in terms of your diabetes are you watching your sugar intake [patient] yeah i usually watch it the form of high what i'm eating but [doctor] i am a big pie fan as well i know what's your favorite type of pie [patient] well you know it's favorite boy i just like pie you know apples cherry chocolate you know bicon [doctor] yeah [patient] i try to try to avoid the bicon because i think it's just all sugar but i do like it [doctor] okay [patient] less [doctor] i like it too alright are you taking the metformin twice a day [patient] not everyday but most of the time [doctor] okay alright and are you checking your blood sugars pretty regularly [patient] i try to [doctor] okay and do you do you know on average how they're running are they running below like one fifty or [patient] yeah it's definitely running below that [doctor] okay your blood sugars are running below [patient] it's it's probably with with with the metformin it seems to be you know one twenty [doctor] good [patient] pretty regular [doctor] good your blood sugars are running in the one twenties that's really good okay alright well i wan na just go ahead and do a quick physical exam okay so i'm looking here at your vital signs and your vital signs look really good i do think you're doing a good job with taking your lisinopril your blood pressure's about one twenty two over seventy right now which is right where we want it your heart rate is nice and slow at sixty seven again which is right where we want it and i do n't appreciate any fever today you you have a normal temperature at ninety eight . four which is really good so i'm just gon na be going ahead and calling out some physical exam findings and i'm gon na let you know what that means when i'm done okay so on your heart exam your heart is in a nice regular rate and rhythm i do n't appreciate any murmur rub or gallop on your lung exam your lungs are nice and clear to auscultation bilaterally on your right knee exam i do appreciate some erythema and edema as well as an area of fluctuance over your right patella now does it hurt when i press [patient] it's a little bit sore [doctor] okay there is pain to palpation of the right anterior knee and i'm just gon na bend your knee up and down does that hurt at all [patient] no no it's just more of the typical grinding that i would feel [doctor] okay there is full range of motion of the right knee and on skin examination there is evidence of a bull's-eye rash over the right knee okay so what does that mean richard so that means that you know you do have some area of some inflammation over the over the right knee where you where you have that tick bite and you do have what we call that bull's eye rash which is what we get concerned about with with lyme disease so let's just talk a little bit about you know my assessment and my plan for you okay so for this first problem of your of your tick bite my concern is that you might have lyme disease based on the presentation of your right knee so i'm gon na go ahead and start you on doxycycline one hundred milligrams twice a day [patient] we're gon na continue that for about three weeks i'm also gon na go ahead and send a lyme titer as well as a western blot to see if you do in fact have lyme lyme disease and we'll have to go ahead and just see how you do with this we you know i'd like to avoid intravenous antibiotics which i think we can avoid but i wanted to see how you do so [doctor] do you have any questions about that [patient] yeah i did n't know what those last two things or just [doctor] yeah so so we are gon na start you on some antibiotics to help help you with this [patient] you know possible lyme disease and i'm gon na just order some blood tests just to see exactly what's going on and then you know sometimes people need intravenous antibiotics because lyme disease can cause problems on other organs like your heart that type of thing [doctor] if not treated appropriately and sometimes we need to give antibiotics through the iv which i'd like to avoid i think that we got this early enough that we can just treat you with some oral antibiotics okay for your second problem of your hypertension you know i think you're doing a really good job let's go ahead and continue you on the lisinopril twenty milligrams once a day and i wan na just go ahead and order a lipid panel just to make sure that everything is okay with your cholesterol how does that sound [patient] that's fine [doctor] great and then for your third problem of your diabetes i wan na just go ahead and order a hemoglobin a1c and continue you on the metformin one thousand milligrams twice a day it sounds like you're doing a good job since your blood sugars are running in the one twenties i do n't think we need to make any adjustments but we'll see what the hemoglobin a1c shows that gives us a an idea of what your blood sugars are doing on a long-term basis how does that sound [patient] okay at what point time do you start kinda checking kidney function i've been told that metformin can possibly cause some kidney issues [doctor] so it can you know your kidney function we've you know i think you've been really lucky it's been normal i checked it about two months ago and it looks pretty good it looks pretty normal but since we're doing blood work on you i can go ahead and order a a basic metabolic panel just to make sure that your kidney function is stable [patient] okay that'd be good [doctor] okay anything else [patient] not that i can think of at this time as soon as i leave [doctor] well you know where to find me okay [patient] alright [doctor] take care bye

ASSESSMENT AND PLAN

1. Tick bite.
 - Medical Reasoning: My concern is that he might have Lyme disease based on the presentation of his right knee.
 - Patient Education and Counseling: The patient and I discussed blood testing to determine if he does in fact have Lyme disease. I explained that Lyme disease can cause problems with other organs if not treated appropriately. We discussed that sometimes antibiotics need to be administered intravenously if oral antibiotics are not given early enough. We will see how he does with a course of oral antibiotics as I would like to avoid intravenous antibiotics.
 - Medical Treatment: Prescription for doxycycline 100 mg twice a day for 3 weeks provided. Lyme titer and Western blot will be obtained to determine if he has Lyme disease.

 2. Hypertension.
 - Medical Reasoning: This is well-controlled at this time.
 - Patient Education and Counseling: The patient and I discussed that he is doing really well monitoring his blood pressure at home.
 - Medical Treatment: Continue lisinopril 20 mg once a day. Lipid panel ordered to assess his cholesterol levels.

 3. Diabetes type 2.
 - Medical Reasoning: He is doing a good job managing his diabetes since his blood sugars are running in the 120s. I do not think we need to make any adjustments, but we will see what the hemoglobin A1c shows as that gives us an idea of what his blood sugars are doing on a long-term basis.
 - Patient Education and Counseling: We discussed that metformin can affect kidney function; however, his kidney function was last checked 2 months ago, and it has remained within normal limits.
 - Medical Treatment: Continue metformin 1000 mg twice a day. Hemoglobin A1c ordered. Basic metabolic panel ordered to assess kidney function.


[doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced ejection fraction ejection fraction thirty five percent and moderate mitral regurgitation alright russell hi how are you doing today [patient] hey document i i do n't know i'm doing alright i guess [doctor] just alright how's it [patient] well [doctor] how's it been since you've had your heart attack have you been have you been doing alright [patient] no i've been seeing you for years since i had my last heart attack in two thousand eighteen but i've been doing pretty good i ca n't believe this happened again i mean i'm doing okay i guess i just feel tired every now and then and but overall i mean i guess i feel pretty well [doctor] okay good were you able to enjoy the spring weather [patient] yeah some i mean i'm hoping now that i've had my little procedure that i'll feel better and feel like getting back out and and maybe doing some walking there is some new trails here behind the rex center and maybe get out and walk those trails [doctor] that will be fine i know you love walking the trails i know you like looking at the flowers because i think you you plant a lot of flowers as well do n't you especially around this time [patient] yeah i do some gardening around the house [doctor] yeah [patient] and you know i really like photography too being able to go out and take nature pictures [doctor] yeah [patient] so i'm hoping to be able to go out and do that [doctor] okay well we'll we'll do what we can here to get you out and going doing all those fun activities again now tell me have you had any chest pain or any shortness of breath [patient] no not really no chest pain or shortness of breath i've been doing some short walks right around the house so like around the block [doctor] okay [patient] but i stay pretty close to the house i've been doing some light housekeeping and i do n't know i seem to be doing okay i think [doctor] okay alright now tell me are you able to lay flat at night when you sleep or [patient] well i mean i i never have truly laid flat on my back i've always slept with two pillows which is normal for me [doctor] okay [patient] so i mean i guess i really do n't have any troubles with my sleeping [doctor] okay good how about are your legs swelling up [patient] nope i've always i always had skinny ankles like like i got dawn knots legs [doctor] well that's cute were you able to afford your medications and are you taking them as prescribed [patient] yeah i've been taking my medicine i got pretty good insurance there through the plant and and so the co-pay is n't too bad [doctor] okay [patient] and i've been taking them because i do n't want my sense to close up and they told me that that to take them this you know all the time and and i've been taking them since i got out of the hospital [doctor] okay well very good i'm glad you're doing that good for you russell and and then please keep that up now tell me are you watching your salt intake and trying to change your diet [patient] yeah so when i was in the hospital they said something about my way my heart pumps now [doctor] mm-hmm [patient] it it's it's a little low and i might keep fluid on my legs if i'm not careful [doctor] right [patient] and it's gon na be hard because you know i i really do like pizza and and they told me that i'm really gon na have to watch salt and they said that there is a lot of salt and pizza [doctor] there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay [patient] well [doctor] alright so why do n't we go ahead and do a quick physical exam on you here i just want to take a look at you your vital signs look good i'm glad to see you're tolerating the medication well i'm gon na go ahead and feel your neck here i do n't appreciate any jugular venous distention and there are no carotid bruits on your heart exam there is a three out of six six systolic ejection murmur it's heard at the left base but that's pretty much the same as last year so we'll continue to monitor that okay let me listen to your lungs here real quick russell your lungs are clear so good good and your extremities i do n't see any swelling or edema on your right radial artery the cath site there is clean and it's dry and intact and i do n't see any hematoma so that's good and there is a palpable rra pulse so russell i did review the results of your ekg which showed normal sinus rhythm good r wave progression and evolutionary changes which are anticipated so let's go ahead and talk about my assessment plan for you for your first diagnosis of coronary artery disease we are gon na have you continue your your aspirin eighty one milligrams daily and brilinta ninety milligrams twice daily and we're gon na have you continue on that high dose statin that atorvastatin you might call it lipitor eighty milligrams daily and then also continue on that toprol fifty milligrams daily okay and i'm also going to refer you to cardiac rehab so for you to get some education about your heart and also give you the confidence to get back exercising regularly now i know patients love the cardiac rehab program i think you will do well does that sound good to you [patient] that sounds good document [doctor] alright so for your second diagnosis here the newly reduced left ventricular dysfunction and moderate mitral regurgitation i think your pumping function will improve in time you know they got you to the lab quickly so i think that heart muscle is just stunned and you're very compliant you're very good with your medications and following through with those so i think it will recover so that said i want you to go ahead and continue continue your lisinopril twenty milligrams a day i do n't think you need a diuretic at this time but i do want to add aldactone twelve . five milligrams daily and then you'll need to get labs next week okay and then we're gon na repeat another echocardiogram echocardiocardiogram in about two months [patient] okay [doctor] okay and then for your hypertension your third diagnosis of hypertension i want your to take your blood pressure just like you would you know every so often and then because your blood pressures actually seem fine at this time so we will continue to monitor that and i think you will tolerate the aldactone well as well [patient] alright sounds good document [doctor] okay well you take care and you have a good evening [patient] yeah you too [doctor] bye

ASSESSMENT AND PLAN

1. Coronary artery disease.
 - Medical Reasoning: The patient's exam is consistent with coronary artery disease.
 - Patient Education and Counseling: We discussed that he should continue to watch his diet and salt intake. We also discussed that the cardiac rehab should help with his confidence with exercising regularly and for his education.
 - Medical Treatment: Continue taking aspirin 81 mg daily Continue taking Brilinta 90 mg twice a day. Continue taking Lipitor 80 mg daily. Continue taking Toprol 50 mg daily. I will refer him to cardiac rehab.

 2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.
 - Medical Reasoning: The patient's physical exam is consistent with this diagnosis.
 - Patient Education and Counseling: We discussed that his pumping function should improve in time. We also discussed that since he is compliant with his medications and presented to the cardiac cath lab quickly, he should recover. I advised the patient that he does not need to start a diuretic at this time.
 - Medical Treatment: Continue taking lisinopril 20 mg a day. Prescription for Aldactone 12.5 mg daily provided. Order for labs provided. Repeat echocardiogram ordered to be completed in 2 months.

 3. Hypertension.
 - Medical Reasoning: This seems stable at this time.
 - Medical Treatment: Continue home blood pressure monitoring.