[doctor] hi , james , how are you ? [patient] hey , good to see you . [doctor] it's good to see you , too . so , i know the nurse told you about dax . [patient] mm-hmm . [doctor] i'd like to tell dax a little bit about you . [patient] sure . [doctor] james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain . [patient] mm-hmm . [doctor] so , james , what happened to your back ? [patient] uh , i was golfing and i hurt my back when i went for my backswing . [doctor] okay . and did you feel a pop or a strain immediately or ? [patient] i f- felt the pop , and i immediately had to hit the ground . i had to just try and do anything to loosen up my back . [doctor] okay . and how long ago did this happen ? [patient] this was saturday morning . [doctor] okay . so , about four days ago ? [patient] mm-hmm . [doctor] okay . um , and what have you taken for the pain ? [patient] uh , i took some tylenol . i took some ibuprofen . [doctor] mm-hmm . [patient] i tried ice . i tried heat , but nothing really worked . [doctor] okay . and , h- how are you feeling now ? are you still in the same amount of pain ? [patient] uh , by monday morning , it loosened up a little bit , but it's still pretty sore . [doctor] okay . any other symptoms like leg weakness , pain in one leg , numbing or tingling ? [patient] uh , i actually felt , um ... i had a struggle in my right foot like dropped foot . i had some struggling with my right leg . i felt that for a while , and it got a little bit better this morning but not much . [doctor] okay . all right . um , so , are you ... how are you doing walking around ? [patient] uh , uh , uh , i'm , i'm not going anywhere fast or doing anything strenuous but i can walk around a little bit . [doctor] uh- . [patient] not too fast . [doctor] all right . okay . um , and any history with your back in the past ? [patient] i actually had surgery about 10 years ago on my lower back . [doctor] okay . all right . now , tell me a little bit about your , your heart failure . you know , i have n't seen you in a while . [patient] mm-hmm . [doctor] how are you doing with your diet ? [patient] um , been pretty good t- taking my medications , watching my diet , trying to , uh , trying to exercise regularly , too . [doctor] okay . so , you're avoiding the salty foods like we had talked about ? [patient] yes . [doctor] okay . and any weight gain or swelling in your legs recently ? [patient] a little bit of weight gain over the summer but nothing , nothing too radical , nothing more than five pounds . [doctor] okay . all right . and any problems laying flat while you go to bed ? [patient] no . [doctor] okay . uh , and lastly , what about your diabetes ? how are you doing with , with that diet ? i remember you have somewhat of a sweet tooth . [patient] yeah . [doctor] jelly beans ? [patient] i love jelly beans , yeah , yeah . that's been a struggle , but i'm getting through it . [doctor] okay . all right . um , and you're watching your blood sugars at home ? [patient] mm-hmm . i monitor it regularly . not always, i can forget, , but i'm pretty good about my measuring it . [doctor] okay . and you are still on your metformin ? [patient] yes . [doctor] okay . all right . all right . now , i know the nurse did a review of symptoms sheet when you checked in . [patient] mm-hmm . [doctor] i know that you were endorsing the back pain- [patient] mm-hmm . [doctor] . and maybe a little weakness in your right leg . um , any other symptoms ? i know we went through a lot . [patient] no . [doctor] okay . um , so , i wan na go ahead and move on to a physical exam , okay ? [patient] mm-hmm . [doctor] hey , dragon , show me the vital signs . so , here in the office , you know , your vital signs look great . they look completely normal , which , which is really good . [patient] good . [doctor] okay ? so , i'm just gon na check you out , and i'm gon na let you know what i find , okay ? [patient] mm-hmm . [doctor] lean up . okay . all right . so , on your physical exam , everything seems fine . [patient] good . [doctor] on your heart exam , i do appreciate a 2 out of 6 systolic ejection murmur , which we've heard in the past- [patient] mm-hmm . [doctor] . so that's stable . [patient] okay . [doctor] on your back exam , you do have some pain to palpation of the lumbar 5 or lumbar spine- [patient] mm-hmm . [doctor] at the level of l5 . [patient] okay . [doctor] you have , you know , decreased range of motion with flexion and extension , and , um , you have a positive straight leg raise . uh , for your strength , you do have a 4 out of 5 on your right and 5 out of 5 on your left . [doctor] so , what does that mean ? what does all that mean ? so , that basically means that , you know , i , i think that you probably , you know , have injured your , your back with a muscle strain , but we're gon na look at some of your results , okay ? [patient] okay , sure . [doctor] hey , dragon , show me the back x-ray . so , in reviewing the results of your back x-ray , this is a normal x-ray of your lumbar spine . there's good boney alignment . i do n't see any abnormality there , which is not surprising based on the history , okay ? [doctor] hey , dragon , show me the diabetic labs . and this is just ... i just wanted to check your last , uh , diabetic labs that we did on you . uh , it looks like your hemoglobin a1c has been a little high at 8 . i'd like to see that a little bit lower around 7 , okay ? [patient] okay . [doctor] um , so , let's just talk a little bit about my assessment and my plan for you . um , so , for your first problem , i think you have an acute lumbar , um , strain . [patient] mm-hmm . [doctor] and i wan na go ahead and prescribe meloxicam 15 milligrams once a day , and i'd like to refer you to physical therapy to kind of strengthen that area . now , if you're still having symptoms , i wan na go ahead and , uh , order an mri- [patient] mm-hmm . [doctor] . just to make sure that you do n't have any disc herniation or anything like that , okay ? [patient] that's fine . [doctor] how does that sound ? [patient] no problem . [doctor] hey , dragon , order meloxicam 15 milligrams once a day . for your next problem , your type 2 diabetes , i would like to increase your metformin to 1,000 milligrams twice daily- [patient] mm-hmm . [doctor] . and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months . [patient] okay . [doctor] all right ? hey , dragon , order a hemoglobin a1c . and for your congestive heart failure , uh , i think you're doing really well with it . um , you know , i wan na just continue you on your current medications , your lisinopril and your lasix . now , do you need a refill- [patient] actually , i- [doctor] of the lisinopril ? [patient] actually , i do . [doctor] okay . hey , dragon , order a refill of lisinopril 20 milligrams once a day . and so , the nurse will come in . she's gon na help you get checked out . i wan na see you again in a couple weeks , okay ? [patient] that's fine . [doctor] um , any questions ? [patient] not at this point . [doctor] okay . hey , dragon , finalize the note .

ASSESSMENT AND PLAN

James Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain.

 Acute lumbar strain.
 • Medical Reasoning: The patient reports feeling a 'pop' and immediate pain while golfing approximately 4 days ago. He has tried Tylenol and ibuprofen without significant relief.
 • Additional Testing: If he continues to have pain, we will obtain an MRI for further evaluation.
 • Medical Treatment: Initiate meloxicam 15 mg once daily.
 • Specialist Referrals: We will refer him to physical therapy to work on strengthening the area.

 Diabetes type 2.
 • Medical Reasoning: He has been compliant with metformin and dietary modifications, but his recent hemoglobin A1c was 8.
 • Additional Testing: Repeat hemoglobin A1c in a couple of months.
 • Medical Treatment: Increase metformin to 1000 mg twice daily.

 Congestive heart failure.
 • Medical Reasoning: He is doing well from this standpoint. He has been compliant with his medications, dietary modifications, and regular physical activity.
 • Medical Treatment: Continue lisinopril 20 mg once daily and Lasix. Lisinopril was refilled today.


[doctor] hello , mrs . peterson . [patient] hi , doctor taylor . good to see you . [doctor] you're here for your hip today , or your- your leg today ? [patient] yes . i hurt my- the- my- top part of my right leg here . [doctor] hey , dragon . i'm seeing mrs . peterson , here , she's a 43-year-old patient . she's here for left leg pain . right leg pain , right leg pain ? [patient] yes . [doctor] um so , what happened to you ? [patient] i was bowling and as i was running up to the lane , i had my bowling ball all the way back , and when i slung it forward , i hit it right into my leg instead of the lane and so then i fell but- yeah- [doctor] did you get a strike ? [patient] no . in fact , i actually dropped the ball and it jumped two lanes over and landed in the other people's gutter . [doctor] terrific , terrific . so , did it swell up on you ? [patient] it- not- did n't seem like it swelled that much . [doctor] what about bruising ? [patient] um , a little bit on the back- back end , that side . [doctor] have- have you been able to walk on it ? [patient] just a little bit . very carefully . [doctor] sore to walk on ? [patient] yes . it's very sore . [doctor] um , and going upstairs or downstairs , does that bother you at all ? [patient] yeah , well , i do n't have stairs , but um , i would avoid that at all costs . [doctor] okay . um , it looks like you had a history of atopic eczema in your past ? [patient] yes . yes , i have eczema . [doctor] okay . and you take uh- uh , fluocinonide for that ? [patient] yes , when it gets really itchy , i'll- i'll use that and it usually takes care of it . [doctor] okay . and , it looks like you have a pre- previous surgical history of a colectomy ? what happened there ? [patient] yes , i had a- um , some diverticulosis and then um , i actually went into diverticulitis and they ended up going in and having to remove a little bit of my colon . [doctor] okay , let me examine you . does it hurt when i push on your leg like that ? [patient] yes , it does . [doctor] okay . if i lift your leg up like this , does that hurt ? [patient] no . [doctor] so , on my exam , you have some significant tenderness to the lateral aspect of your um right upper leg . you do n't seem to have any pain or tenderness with flexion or extension of your um your lower leg . um , are you taking anything for it right now ? [patient] i've been going back and forth between taking ibuprofen and tylenol . [doctor] okay . well , my impression is that you- you probably have a contusion , but let's take a look at your x-ray first . hey , dragon . show me the x-ray . yeah , so if you look at this , this is a normal femur . um , really do n't see any evidence of a fracture or any swelling , so it's essentially , a normal x-ray . so , what we're going to do is , i'm going to start you on um an anti-inflammatory . it's going to be mobic 15 milligrams uh , once a day . i want you to use some ice for the pain , um , and it should , honestly , just being a contusion , get better in the next week or so . if it's not getting better , of course , come on back and- and see me . [patient] okay , sounds good . [doctor] hey , dragon . go ahead and um , pres- do the orders and um , procedures uh , as described . come with me , and uh , i'll get you checked out . dragon , go ahead and finish off the note .

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended Mobic 15 mg once a day. She will use ice for pain. She will follow up as needed.
 "


[doctor] patient is pamela cook . medical record number is 123546 . she's a 36-year-old female post bilateral reduction mammoplasty on 10-10 20-20 . [doctor] hey , how are you ? [patient] good . how are you ? [doctor] i'm doing well . it's good to see you . how have you been ? [patient] i've been doing good . [doctor] great . how about your breasts , are they doing all right ? [patient] great . [doctor] are you having any chills , fever , nausea , or vomiting ? [patient] no . [doctor] good . all right . let's take a peek real quick . [patient] sure . [doctor] how's life otherwise ? pretty good ? nothing new ? [patient] no , just enjoying summertime . [doctor] okay . how's your family ? [patient] they're good . [doctor] good . all right . i'm going to take a look at your breast now . if you would just open up your gown for me . [doctor] everything looks good . [patient] yeah . [doctor] how's your back pain ? [patient] i'm not really having any more . [doctor] any hard spots , lumps , or bumps that you've noticed ? [patient] i did when i came in last time when i saw your pa , ruth sanchez in march . she said i , she said she found a lump right here under my left breast , but i have n't felt it since then . but i did the massages . [doctor] okay , well . that that's good . uh , it's probably just the scar tissue , but everything looks good and you're healing wonderful , so . [patient] i told her that the scars here was kind of bothering me and i got scar gel . i was using it everyday , but i do n't think i need it now . [doctor] yeah , that scar did widen a little bit . let me take a closer look , hang on . this one widened a little too , ? the incisions are well healed though with no signs of infection or any redness on either breast , so i'm not concerned . [patient] yeah , but this one just bothered me a little bit more . [doctor] i understand . um , you can close your gown now . [doctor] the only thing that is really going to help out that is to uh , to cut it out and re-close it . [patient] [doctor] and you do n't want that , ? [patient] i mean , not right now . [doctor] um , you want to come back and revisit um , maybe six months ? [patient] yeah , i will do that . i still have n't , i still have some more of the gel and i can try using that again . [doctor] okay . keep doing that twice a day . the gel is going to lighten the color a little bit , which is already pretty light . um , but , just in that area , and it's high tension , so it's going to rub a little bit . [patient] yeah , but it kind of bothers me a little bit . [doctor] uh , i do see that . like i said , the only way to really fix that is to cut it out . [patient] uh- . [doctor] um , let's take a look in six months and then we'll go from there . sound like a plan ? [patient] but we have n't hit a full year yet . [doctor] i know . um , i would n't do any revisions anyway for scar tissue until we're at least a year out anyway . [patient] okay . [doctor] so let's wait those six months . you can keep using uh , the mederma scar gel twice a day . massage and scar gel will help for the scars . um , you can put it on other scars too , if you need . [patient] okay . [doctor] um , so that's what i would do . let's just get some pictures today so we can keep up um , with them . and keep an eye on these scars and then we'll go from there . [patient] sounds good . [doctor] all right , well it's good to see you . i'm glad you're doing well . [patient] yeah , same here . [doctor] all right . well , i'm going to tell the front desk six months and we'll revisit those scars . [patient] all right . [doctor] thank you . they're gon na come get your photos now , okay ? [patient] okay .

ASSESSMENT

• Status post bilateral reduction mammoplasty.

 Pamela Cook is a 36-year-old female who is status post bilateral reduction mammaplasty on 10/10/2020. There is some widening of the scar tissue bilaterally.

PLAN

- Obtain bilateral breast photos today to monitor scarring.
 - Continue Mederma scar gel and incisional scar massage twice daily.


[doctor] hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that [patient] yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some burning and some stinging and looked down and saw a blister i did n't think too much of it because it was on the pad of the bottom of my foot around my heel and i just had been walking on the front part of my foot i started to notice a foul smell and my wife mentioned something to me the other day and i noticed my dog was also smelling my socks a lot and so we looked and saw that the blister had become unroofed or the the top part of the skin of the blister became undone and then underneath it was just this really thick soft mushy skin that had a bad smell with some yellow drainage and so and barbara called the primary care doctor who then got me in to see you he started me on some antibiotics about six days ago and i never had any nausea or vomiting but my wife checked my temperature it was about ninety nine point seven and then at one point i had to put on an extra blanket in bed because i had some chills and when i started the antibiotics it started to feel pretty good but we've now noticed that it has turned black around the outside of the wound and i'm getting some cramping in my calf muscle as well and so there was a red streak also that was coming up the front part of my my ankle along the inside portion of my calf muscle and it's super super hot and so they wanted me to take a have have you look at it [doctor] okay thank you for sharing that history with me and did you complete that course of antibiotics [patient] i think he called in ten days' worth and i'm on day six or seven right now i know i've got about two or three days left [doctor] okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now [patient] yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point [doctor] okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that [patient] yeah my my a1c is six point seven it's pretty well controlled [doctor] okay [patient] i used to be on an insulin pump and i had an a1c that at one point was like thirteen but we worked with an endocrinologist to get it down to where it's at now i've been six point seven for probably two years now and i rarely have a blood sugar that goes over two hundred i check two or three times a day if i feel weird i'll check it again but i noticed my sugars have probably been trending in the three to four hundreds the last two weeks and then i had one spike at one point at like five or six hundred that got our attention and i think that's also what made my wife call the primary care doc [doctor] okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park [patient] yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now [doctor] absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there [patient] i do n't feel that right there [doctor] okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure [patient] no not really so you're gon na continue the antibiotics that i'm on and possibly extend or call in a new antibiotic depending on the culture [doctor] correct [patient] if i heard [doctor] yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy [patient] okay sounds good [doctor] alright

ASSESSMENT

Right non-healing diabetic foot ulcer.
 Diabetes.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed.

 In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results.


[doctor] hi andrea , how are you ? [patient] i'm doing well . how are you ? [doctor] doing well . uh , so i know the nurse told you about dax . i'd like to tell dax a little bit about you . okay ? [patient] okay . [doctor] so , andrea is a 52-year-old female with a past medical history significant for rheumatoid arthritis , atrial fibrillation , and reflux who presents today for her annual exam . so andrea , it's been a year since i saw you . how are you doing ? [patient] i'm doing well . so , i've been walking like you told me to and , um , exercising and doing yoga , and that's actually helped with my arthritis a lot , just the- the constant movement . so , i have n't had any joint pain recently . [doctor] okay . good . so , no- no issues with any stiffness or pain or flare ups over the last year ? [patient] no . [doctor] okay . and i know that we have you on the methotrexate , are you still taking that once a week ? [patient] yes , i am . [doctor] okay . and any issues with that ? [patient] no . [doctor] no . okay . and then in terms of your a-fib , how are you doing with that ? are you having any palpitations ? or , i know that you've kind of been in and out of it over the past , you know , year or so . [patient] yeah . i've still been having palpitations . the- the last one i had was about a week ago . i've noticed that when i start to get stressed , um , they start to flare up again . so , i've been trying meditation , trying running with my dog to try and relieve the stress but it has n't really been working . [doctor] yeah . i- i know that you had called , um , last month and we- we did that event monitor for you , uh , which we'll take a look at in a few minutes . okay ? [patient] okay . [doctor] um , how about um , your reflux ? you know , we had placed you on the protonix , uh , has that helped ? and i know that you were gon na do some dietary modifications . [patient] yeah . i cut out soda and that- that's helped- seemed to help , and the medication's been helping too . i have n't had a flare up in over , i think , five months . [doctor] okay . all right . um , so , you know , i know that you did the review of systems sheet when you checked in and , you know , you had- you know , you endorsed the palpitations and you had some nasal congestion . any other symptoms ? you know , chest pain , shortness of breath , nausea or vomiting ? [patient] no , nothing like that . just the nasal- nasal congestion because of my allergies . [doctor] okay . all right . okay . well , i'd like to go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] all right . hey dragon , show me the vital signs . okay . so , you're in- here in the office today , it looks like , you know , your heart rate's really good today . it's- it's nice and controlled so that's good . um , i'm just gon na take a look into your heart and lungs and- and i'll let you know what i find . okay ? [patient] okay . [doctor] okay . so , on physical examination , um , you know , everything looks really good . on your heart examination , i do appreciate a slight 2/6 systolic- systolic ejection murmur , um , which we've heard in the past so i'm not worried at that . you're in the- a nice regular rate and rhythm at this time . your lungs are nice and clear . on your right elbow , i do notice some edema and some erythema . does it hurt when i press it ? [patient] yeah , it does a bit . [doctor] okay . so , she has pain to palpation of the right elbow . um , and you have no lower extremity edema , okay ? um , so i wan na go ahead and just take a look at some of your results . okay ? [patient] okay . [doctor] hey dragon , show me the event- event monitor results . okay . so , you know , this is the results of your event monitor which shows that , you know , you're in and out of a-fib , you have what we call a conversion pause . you know , you're in a-fib , you pause , and then you go back to regular rhythm . so , we'll talk about that , okay ? [patient] okay . [doctor] hey dragon , show me the autoimmune panel . so , looking here at your autoimmune panel , everything looks good , it looks like you're- you know , everything is well controlled with your rheumatoid arthritis on the methotrexate . okay ? so , let me just go over a little bit about my assessment and my plan for you . okay ? [patient] okay . [doctor] so for your first problem , your rheumatoid arthritis , again , everything looks good . i wan na just continue you on the methotrexate 2.5 mg , once weekly . um , and uh , if you need a referral back to see the rheumatologist , let me know , but i think everything seems stable now . do you need a refill of the methotrexate ? [patient] yes , i do . [doctor] okay . hey dragon , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ? [patient] okay . [doctor] hey dragon , order a referral to cardiology . and for your last problem , the reflux , you know , i wanna- i want you to just continue on the protonix , 40 mg a day . continue with your dietary modifications , you know , avoiding coffee and spicy foods , that type of thing . okay ? and then let me know if you have any other issues with that , okay ? [patient] will do . [doctor] any questions ? [patient] no , i do n't . [doctor] okay . all right . it was good to see you . [patient] good seeing you . [doctor] hey dragon , finalize the note .

ASSESSMENT AND PLAN

Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.

 Rheumatoid arthritis.
 • Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal.
 • Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today.
 • Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know.

 Atrial fibrillation.
 • Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause.
 • Specialist Referrals: We will refer her to cardiology for a cardiac ablation.

 GERD.
 • Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months.
 • Medical Treatment: Continue on Protonix 40 mg daily.
 • Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers.


[doctor] dictating on donald clark . date of birth , 03/04/1937 . chief complaint is left arm pain . hello , how are you ? [patient] good morning . [doctor] it's nice to meet you . i'm dr. miller . [patient] it's nice to meet you as well . [doctor] so , i hear you are having pain this arm . is that correct ? [patient] that's correct . [doctor] okay . and it seems like it's worse at night ? [patient] well , right now the hand is . [doctor] mm-hmm . [patient] and the thing started about two weeks ago . i woke up about two o'clock in the morning and it was just hurting something awful . [doctor] uh- . [patient] and then i laid some ice on it and it finally did ease up . [doctor] okay , that's good . [patient] so i got up , i sat on the side of the bed and held my arm down , thinking it would , like , help the circulation , but it did n't . [doctor] okay , i see . [patient] and so , after a while , when it eased off , maybe about four , five am , i laid back down and it did n't start up again . [doctor] mm-hmm , okay . [patient] um . i went back to sleep but for several nights this happened , like , over and over . so , i finally went to see the doctor , and i do n't really recall her name . [doctor] okay . yeah , i think i know who you're talking about , though . [patient] um , she's the one who sent me to you , so , i , i would , i would think so . but when i went to her after the third time it happened and she checked me out , she said it was most likely coming from a pinched nerve . [doctor] probably . uh , do you notice that moving your neck or turning your head seems to bother your arm ? [patient] uh , no . [doctor] okay . is moving your shoulder uncomfortable at all ? [patient] no . [doctor] and do you notice it at other times besides during the night ? [patient] um , some days . if it bothers me at night , then the day following , it usually will bother me some . [doctor] okay . and do you just notice it in the hand , or does it seem to be going down the whole arm ? [patient] well , it starts there and goes all the way down the arm . [doctor] okay . have you noticed any weakness in your hand at all ? [patient] uh , yes . [doctor] okay . like , in terms of gripping things ? [patient] yeah . [doctor] okay . [patient] uh , this finger , i hurt it some time ago as well . [doctor] really ? [patient] yeah . it does n't work properly . or , it works very rarely . [doctor] gotcha . and did i hear that she gave you some prednisone and some oral steroids , or ? [patient] uh , well , she gave me some numbing medicine . it helped a little bit . the other two were a neck pill and gabapentin . uh , you should have my full list in your notes , though . since then it has n't really bothered me at night . also , just so you know , i am a va and i'm one percent disabled from this leg , um , issues from my knees down to my feet . [doctor] okay . is it neuropathy ? [patient] uh , yep . [doctor] gotcha . that is good to know . all right , well , let's go ahead and take a look . [patient] okay . [doctor] all right . so , to start , i'm gon na have you do something for me . uh , just go ahead and tilt your chin as far as you can down to your chest . okay , good . and now , go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay . and now , come back to normal , just look and turn your head as far as you can that way . great . and now , as far as you can towards that wall . uh , does that seem to bother you at all ? [patient] no . well , actually , i do feel a little strain . [doctor] okay . so , you feel it in the neck a little bit ? [patient] yeah , just a little strain . [doctor] okay . uh , now squeeze my fingers as hard as you can with both hands . great . now , hold your arms like this . [patient] okay . [doctor] and i'm going to try to strain your arms and try to keep them as stiff as you can . do n't let me strain it . okay , good . good . now , when i , i'm just touching your hands like this . does it seem to feel about the same in both hands ? [patient] uh , yes . [doctor] okay . all right . so , i do agree with betty . uh , more than likely , this seems like it would be coming from your neck . that's the most common reason that causes what , what you're experiencing . and i looked at an x-ray of your neck , and you do seem to have a lot of arthritis there , and there does seem to be potential for a disc to be pushing on a nerve . and now , what i do n't have is an mri , which would show me , uh , kind of exactly where the nerve roots are getting pinched off . [patient] i see . [doctor] so , gabapentin can help a little bit with the nerve pain , and what i would like to do is potentially set you up for an epidural . and what that is is it , it's a focused anti-inflammatory medicine , excuse me , that works behind the nerve roops that , nerve roots that we are thinking might be getting squished off . it can often help alleviate your symptoms , and i do need to get an mri of your neck . um , i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so , what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see right where i need to put the medicine for your epidural . uh , what do you think of that ? [patient] i think that sounds good to me . [doctor] okay , good . and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list . [patient] uh , no , i do n't . [doctor] okay , good . and what i would have you do is continue with the gabapentin . um , are you taking 300 or 100 ? [patient] um , not sure . my lady friend helps me handle this stuff . [doctor] okay . [patient] i am taking eliquis , though . [doctor] okay . um , so whatever you are doing you can just keep doing it , and i'm going to set you up for the epidural and imaging study , um , just so i know right where to put the medicine . and i will follow up with you after s- um , that's in . we can do the shot , just to make sure your arm is feeling better . sound good ? [patient] sounds good . for the last couple of nights , though , my neck has not been bothering me . [doctor] okay . s- um , so , presumably what's happening , then , is when you're sleeping your neck is kind of gets off-tilt , uh , kilter , and it compresses the nerve roots there . now , if you think you're doing fine , we could hold off , but at the very la- least , i'd like to update that mri of yours and see what's going on , because probably this is something that will likely flare up again . [patient] yeah , it , it has been for the last week , so , i understand . [doctor] okay . all right . well , do you want to do that work-up and do the epidural , or do you think you're doing fine and you want to wait ? [patient] well , my hand is still bothering me . [doctor] okay . so , you're saying your neck is not bothering you but the hand is . okay . so then , let's just stick with the plan . mri of the neck , so we can see where the nerve roots may be compressed , that's giving your hand the issue . and then , we're going to set you up with the epidural . [patient] okay . sounds good . [doctor] all right . so , keep going with the gabapentin . i will order the imaging of your neck , and the shot will hopefully help some with those symptoms in your hand , and then we'll follow up afterwards . [patient] all right . is the mri today ? [doctor] um , you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute , and then roy will come in and get things scheduled as soon as we can . [patient] all right . [doctor] all right . well , it was nice meeting you , my friend . [patient] you as well . thank you . [doctor] physical exam , elderly white gentleman presents in a wheelchair . no apparent distress . per the template , down through neuro- neurologic . one plus bilateral biceps . triceps brachioradialis . reflexes bilateral all negative . follow up and take out the lower extremities . gait not assessed today . strength and sensation is per the template . uh , upper and lower extremities . musculoskeletal , he is non-tender over his cervical spine . he does have mildly restricted cervical exte- extension . right and left lateral rotation which is symmetric , which gives him mild lateral neck pain but no radi- radicular pain . spurling's maneuver is benign . [doctor] paragraph , diagnostics . cervical x-ray 6421 . cervical x-ray reveals significant disc degeneration at c56 , and to a lower extent c45 and c34 . significant lower lumbar facet arthropathy c67 and c7-t1 is difficult to visualize in the current x-rays . [doctor] paragraph , impression . number one , left upper extremity neuropathy suspicious for cervical radicularopathy . possible contribution of peripheral neuropathy . number two , neck pain in the setting of arthritis disc degeneration . [doctor] paragraph , plan . i suspect that this is a flare of cervical radicularopathy . i'm going to set him up for a cervical mri , and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .

ASSESSMENT

• Left upper extremity neuropathy, suspicious for cervical radiculopathy, possible contribution of peripheral neuropathy
 • Neck pain in the setting of arthritis and disc generation

PLAN

I suspect that this is a flare of cervical radiculopathy. I am going to set him up for a cervical MRI. We will tentatively plan for a left C7-T1 epidural afterwards, although the exact level will be pending the MRI results. He will continue his home exercise program as well as twice daily gabapentin. We will follow up with him afterwards to determine his level of relief. He denies any blood thinners.

 This plan was discussed in detail with the patient who is in agreement.


[doctor] okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right [patient] yes [doctor] so can you tell me about that how are you doing [patient] well i've been doing okay but i've had this wound on my right foot for a couple of weeks and it's not getting better i saw my pcp and they referred me to you i i used to see a podiatrist and a couple of years ago but they moved and i was n't able to get another one [doctor] okay and how long have you had the wound [patient] about two to three weeks [doctor] okay have you had any kind of trauma to that foot [patient] no i bought a new pair of shoes to travel with and the neuropathy i guess i did n't feel that they were too tight at first it was just a blister but it looked a lot worse now i've been putting a band-aid on it and [doctor] okay and so did your doctor put you on any antibiotics when they they saw your foot [patient] yes i finished the course yesterday the wound looked about the same though [doctor] okay now does it hurt [patient] no i ca n't feel it [doctor] okay now have you had any other symptoms like fever chills drainage from the wound or anything along those lines [patient] no but when i take my sock off sometimes it sticks to the wound even when i put a band-aid on [doctor] okay well are you still wearing those same shoes that cause the problem [patient] no i'm upset [doctor] i'm so upset too i love those shoes [patient] no i'm so upset i i love those shoes [doctor] okay so what kind of shoes are they [patient] they're hoka's [doctor] ah so where did you get them [patient] i got them at rei couple of years ago [doctor] they're pretty good about helping you to fit your fit you in a shoe are n't they [patient] yeah [doctor] so what do you like about them [patient] they are comfortable they are easy to take on and off and they provide good stability [doctor] that's good so you've had some issues with stability sometimes or [patient] yes [doctor] okay okay well another question i want to ask you is how is your diabetes doing [patient] i do n't think it's too bad my last hgb a1c was a little over eight [doctor] okay alright well let me just do a quick physical exam okay for vital signs your temperature is ninety eight . one your vital signs look good your heart rate is seventy two respirations sixteen blood pressure is one ten over sixty five okay so on your foot exam let's see there is a one by two inch circular wound on the dorsal aspect of the lateral right foot it is just proximal to the right fifth to the fifth mtp joint and there is some yellow slough present with minimal granulation tissue there's no surrounding erythema or cellulitis and there's no evidence of fluid collection there's no necrosis there is no odor i do not appreciate any bony exposure on on vascular exam there are palpable bilateral femoral and popliteal pulses there are no palpable dp or pt pulses but doppler signs are present okay so does this hurt when i touch it here [patient] no it's okay [doctor] okay alright so i've reviewed the results your right foot x-ray that we did before you i came in the room and this shows no evidence of osteomyelitis which means there is no evidence of bone infection so that's really good so let me tell you a little about my assessment and plan for you so for your first problem your diabetic foot ulcer so i want to order an ankle brachial index abi to determine the blood supply to your foot to see if you can heal this wound i'm also gon na perform a debridement here in the office to take off some of the dead tissue and then next i'm going to prescribe a collagenase ointment to be applied to the wound once daily and then cover with a dry sterile dressing now we will continue this until we see the wound shrinking and a nice pink tissue is present and i want you to wear a surgical shoe to take pressure off of the area okay so i do n't think any more antibiotics are needed at this time and i want to see you again in two weeks so we may need to refer you to a vascular specialist if the abi indicates your blood supply is not optimal for wound healing okay [patient] okay [doctor] okay so for your diabetes it's gon na be very important to get your diabetes under control in order to get the wound to heal so we might even go ahead and get a diabetic consult so that we can go over some some maybe some ways you can modify your diet without a being too much but maybe that can bring down your hemoglobin a1c into a little bit better level okay [patient] okay [doctor] alright do you have any other questions [patient] no [doctor] okay

ASSESSMENT

1. Right foot diabetic ulcer.
 2. Diabetes.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. At this time, I have recommended that we obtain an ankle brachial index ABI to determine the blood supply to his foot to see if he can heal this wound. I have also performed a debridement in the office to remove some of the dead tissue. I have prescribed a collagenase ointment to be applied to the wound 1 time daily and instructed him to cover with a dry sterile dressing. He will continue this until we see the wound shrinking and the nice pink tissue is present. I have also recommended that the patient be placed in a surgical shoe to take pressure off the area. I do not think that antibiotics are needed at this time. He may need to see a vascular specialist if the ABI indicates that his blood supply is not optimal for wound healing.

 Regarding his diabetes, I explained the need for controlling his diabetes and the effects this will have on wound healing. I have recommended a diabetic consultation to discuss diet modifications to bring his hemoglobin A1c to a better level.


[doctor] good morning julie how are you doing this morning [patient] i've been better my primary care doctor wanted me to see you because of this this knee pain that i've been having for about six months now [doctor] okay and do you remember what caused the pain initially [patient] honestly i do n't i ca n't think of anytime if i fell or like i i've really been trying to think and i ca n't really think of any specific event [doctor] okay now it it says here that it's in both knees is that correct [patient] yes both my knees [doctor] okay it kinda try let's let's try describing the pain for me please [patient] yeah it's kind of feels like it's like right behind my kneecaps [doctor] okay [patient] and it's like a deep achy pain [doctor] a deep achy pain okay what kind of activities makes the pain feel worse [patient] let's see so anytime so if i'm sitting at my desk and i get up i have a lot of pain so anytime from like standing up from sitting for a while or even going up and down the stairs [doctor] okay so you work from home [patient] i do [doctor] okay okay so there is a lot of desk setting at home is your office upstairs or is it i mean do you have to go up or downstairs to get to it [patient] no well first thing in the morning but otherwise it's downstairs [doctor] okay okay how do you like working from home [patient] you know it has it's plus and minuses [doctor] okay [patient] i like it though my i like my commute [doctor] yeah [patient] i love it [doctor] and the parking i'm sure the parking is [patient] and the parking is great [doctor] yeah i you know if i could do telehealth visits all day long i would be totally happy with that yeah and just set it home and do those so you mentioned is there anything that makes that pain feel better [patient] usually after like if i feel that pain and then i just it does get better [doctor] okay now you mentioned earlier that you tried some things in the past what have what are they and did they work at all [patient] yeah i've done some ibuprofen or aleve sometimes some tylenol and that does help [doctor] okay [patient] it takes the edge off [doctor] okay but you're never really pain free is that what i hear you saying [patient] not really unless i'm like really just resting which i hate to do but otherwise any type of movement especially from sitting it causes pain [doctor] okay so are you active other than going up and down the steps to your office [patient] very i'm a big runner i love to run i run about five to six miles a day but with this knee with with these knee pain that i've been having it's i barely can even do half a mile [doctor] yeah you know what that's that's i am a biker and i know that once you get that into your you know you have loved doing that activity it's so frustrating when you ca n't it's almost like a it's almost like a dry it almost becomes a drug when you get up [patient] exactly [doctor] yeah [patient] it's [doctor] okay so have you noticed any redness or swelling in your knees [patient] no [doctor] okay and have you ever injured your knees before [patient] you know despite how active i am i you know i've never [doctor] okay [patient] injured or broken a bone [doctor] okay great so let's go ahead and do a i just wan na take a look here i reviewed your vitals and overall they look good your blood pressure is one twenty over seventy your your heart rate is sixty and your respiratory rate is fourteen those are all phenomenal numbers as i listened to your heart it is at a regular and a slower rate but i do n't hear any extra sounds so there is no murmurs as we go through that now on musculoskeletal exam you have a normal gait i watched you you know kinda walk in here this morning your strength i just wan na check it when i go ahead and i want you to move your leg okay your muscle strength is is good you do have a three out of five for abduction of your legs bilaterally and that's you know kinda bringing your legs in the remainder of your muscle strength for your lower extremities is a five out of five now let me focus specifically on your knee examination i do n't see any redness or ecchymosis or warmth of the skin and those are big words you know i do n't see any bruising or or that redness there is no effusion that's just like a fluid underneath the knee i do n't appreciate that any at all you do seem to have some tenderness when i palpate and you do have a positive patellar grind test when you stood up i could feel that as we went through there you did say you had that knee pain with squatting but your lachman your anterior and posterior drawer and mcmurray test are all negative bilaterally neurologically and your your your lower extremities your patella and your achilles reflex are symmetrical and that's good so i did review the x-rays of both your knees which shows no fractures or osteoarthritis so based on what you told me and reviewing the mri that you had done before you came in your symptoms are consistent with patellofemoral pain syndrome and this is a really common condition that we see that causes knee knee pain especially in really active young people that's probably why i do n't get it when i'm riding my bike forever and ever now this condition has to do with the way your kneecap moves across along the groove of your thigh bone your femur so for pain i want you to continue to take the ibuprofen or any other anti-inflammatories you know aleve or any of those as you need it to help with the pain now i am going to recommend physical therapy well they will show you a number of lower extremity exercises this is probably one of the best things that you can do and this will help increase your lower extremity strength your mobility and correct any incorrect running mechanics that you might have do you have any questions for me [patient] so will i be able to run again [doctor] absolutely my goal is to get you out there and maybe we can cross pads on the the bike trail some day you are gon na have to take it a little bit easy for now but we are gon na get you back and once we do that i think you will be really pleased is there anything else [patient] no i think that's it [doctor] okay have a great day [patient] okay you too [doctor] thank you [patient] bye

ASSESSMENT AND PLAN

1. Patellofemoral pain syndrome, bilateral.
 - Medical Reasoning: After reviewing her x-ray, previous MRI, and exam findings, her symptoms are consistent with patellofemoral pain syndrome.
 - Patient Education and Counseling: We discussed the nature of this condition in detail. I encouraged the patient to be conservative with her physical activity for now.
 - Medical Treatment: Continue with over-the-counter NSAIDs for pain relief We are going to refer her to physical therapy to help strengthen her lower extremities, increase mobility, and demonstrate proper running mechanics.


[doctor] hey , ms. hill . nice to see you . [patient] hi , dr. james , good to see you . [doctor] hey , dragon , i'm seeing ms. hill . she's a 41-year-old female , and what brings you in today ? [patient] um , i am having a lot of pain at the end of my right middle finger . [doctor] what did you do ? [patient] a little embarrassing . um , i got rear-ended , slow motor , uh , vehicle accident , and i got really angry with the person who hit me , so i went to flip him the bird , but i was a little too enthusiastic . [patient] and i hit the ceiling of the car . [doctor] okay . when did this happen ? [patient] uh , it was saturday , so about four , five days ago . [doctor] five days ago . what were you doing ? were you , like , stopped at a stoplight ? a stop sign ? [patient] yes . so i was stopped at a four-way stop , and it was not my turn to go . there were other cars going , and the person behind me just was n't watching . i think they were texting and rear-ended me . [doctor] how much damage to your car ? [patient] uh , not too much . the , the trunk crumpled up a little bit . [doctor] okay . and no other injuries ? just the finger ? [patient] just the middle finger . [doctor] so you would've escaped this accident without any injuries ? [patient] yes . uh , i'm not proud . [doctor] okay . um , so four days of right middle finger pain- [patient] yes . [doctor] . after a motor vehicle accident . [patient] yes . [doctor] all right . um , let's look at your x-ray . hey , dragon , show me the last x-ray . so what i'm seeing here is on the tip of this middle finger , you actually have a fracture . so you have a distal phalanx fracture in the middle finger . very ... [patient] great . [doctor] very interesting . let me check it out . um , so does it hurt when i push right here ? [patient] yes . [doctor] and does that hurt ? [patient] very much so . [doctor] what about down here ? [patient] no . [doctor] okay . so generally , your exam is normal other than you've got tenderness over your distal phalanx of your right middle finger . um , so your diagnosis is distal phalanx fracture of the middle finger or the third finger . and i'm gon na put you on a little bit of pain medicine just to help , just , like , two days' worth . okay , so tramadol , 50 milligrams , every six hours as needed for pain . i'm gon na dispense eight of those . [patient] okay . [doctor] and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ? [patient] yes . so i'm taking digoxin for afib . will the tramadol be okay with that ? [doctor] it will be okay . so you have atrial fibrillation . [patient] yes . [doctor] you take digoxin . all right . any other questions for me ? [patient] no , that's it . thank you . [doctor] you're welcome . hey , dragon , go ahead and finalize the recording , and , uh , come with me . we'll get you checked out .

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I recommend a prescription for Tramadol 50 mg every 6 hours as needed for pain, dispense 8. She is provided a finger splint and will return in 2 weeks for a follow-up x-ray. All questions were answered.
 "


[doctor] next patient is paul edwards , date of birth is january 15th 1962 . so he's a 59 year old hiv positive gentleman here for hypogonadism . patient was last seen on november 24th 2020 . his notable things are number one , he is on 1 milliliter every 10 days , uh , his levels were less than 300 to begin with . he's on finasteride currently . he also takes cialis daily so he takes all his pills just from me . um , patient's other area of concern is gynecomastia which is ... which we will discuss with him today . his last psa was 0.66 and his last testosterone was greater than 1,500 . [doctor] hey , how are you today ? [patient] all right , how have you been ? [doctor] i'm good . [patient] good , good . [doctor] have you lost some weight or are you at least putting on some muscle ? you look trim . [patient] no , i think i'm pretty much the same as i've always been . [doctor] really ? okay , maybe it's just your black shirt . makes you look thin . [patient] yeah , i guess that's it . [doctor] so health wise , how is everything going ? [patient] good , the testosterone's going well . [doctor] that's great . [patient] uh , it helped me out . i feel good , more vigorous , sleeping well and i think it's having some positive effects . not so much physically because like i said i've- i've been this way my whole life , but i'm seeing some good improvements in my bloodwork . [doctor] okay , well that's good . [patient] so the finasteride i'm only taking half a pill , it's the 5 milligram one . [doctor] yeah , i remember you telling me that . [patient] and cialis , on the days i work out i take 5 milligrams otherwise i take two and a half milligram pills , but , uh , i have been out of it . [doctor] okay . [patient] but overall i'm doing well , i'm actually taking the correct steps to get my life together . [doctor] good . it's always great to hear . well let's take a look . uhm , i'm gon na listen to your heart and lungs . [patient] okay . [doctor] please use my general exam template , all right . just take a few breaths . [patient] okay . [doctor] in and out . [patient] okay . [doctor] all right , everything sounds good , no concerns there . [patient] great . so i wanted to show you something . [doctor] sure . [patient] look at this . [doctor] okay , this is your cholesterol ? [patient] yeah , my cholesterol and triglycerides . uh , i used to have high triglycerides , you see they were 265 milligrams per deciliter , and i took my first dose of the testosterone on the 28th . [doctor] right . [patient] now 5 months later look at my numbers . [doctor] wow , that's remarkable . [patient] is it the test ? it's the only change . [doctor] i do n't know , i have n't honestly seen many guys over the years that have cholesterol problems and this . i mean there's a big correlation between diabetic control and testosterone replacement , meaning those who get good levels of their test see their diabetic control improve . [patient] yeah . [doctor] but i have n't seen a lot of data on the impact on cholesterol . regardless , we will take it . [patient] i agree . i was very impressed with my triglycerides and was just wondering if the test may be what's helping . [doctor] yeah , that's an unbelievable difference . [patient] 145 milligrams per deciliter from 265 milligrams per deciliter is awesome . i also read that it- it's cardioprotective . [doctor] absolutely . [patient] my red blood cell count has increased . [doctor] yeah , i saw that . it's fine though . [patient] stable . [doctor] your psa today is also , uh , is good also . it's , uh , .6 i think . [patient] yeah . , is it ? [doctor] yeah , it was .5 last year and anything under 4 is good . [patient] nice , that's good news . [doctor] so it just needs to be checked every year or so . [patient] so in terms of , uh , estrogen control i've been hearing that indole-3-carbinol , or broccoli extract , supposedly can improve my estrogen levels . have you ever heard of it ? [doctor] yeah , i've heard of it but i have n't had anybody consistently use it . i mean , your levels are fine and we checked your estra- estradiol and it was not elevated , so . [patient] okay . [doctor] i would argue that we could test that in the fall if you want , but we do n't need to do , uh , do any more tests ... any more than test once a year , excuse me . [patient] okay , what about increasing my testosterone to 175 milligrams ? i'm at 140 now . [doctor] well , your levels are high . [patient] are they right now ? [doctor] well , i mean they were last time . [patient] yeah but i just- just injected though , or i had right before that was taken . [doctor] i know . i know you had then , uh , when did you inject this time ? [patient] i figure i'm on my eighth day today . [doctor] okay . [patient] so i'm due to dose on thursday or friday . [doctor] all right . [patient] i have a little med calendar and i put checks and ts on it . that helps me . [doctor] that's a great idea . so look , the biggest issue i've seen , even if your levels today are around 700 , is that your peaks are getting greater than 1,500 , putting you at a higher chance of needing to come off due to blood thickness . and your risk will only astronomically go up the higher the dose that we go on . [patient] okay . [doctor] you look well , your levels are good and you're feeling well . [patient] yeah , i'm feeling good . [doctor] i'm going to be blunt . unfortunately this happens often where you're feeling good but you want to feel really good . i mean , i get it and this is why people get into problems with this stuff , right ? it's like , back in the day when it was n't prescribed by doctors and people would get it at gyms and stuff and they would take huge doses . and then they would have a heart attack at 50 . [patient] yeah , they have to be taking a lot . [doctor] likely they are taking more than testosterone , but still . [patient] and they are taking stuff for a long time . [doctor] true . but right now i would not change your dose . [patient] okay . [doctor] make sense ? [patient] it does , i appreciate the discussion . [doctor] no problem . what pharmacy are you using ? have you changed it or anything ? [patient] no changes , i use walmart pharmacy . i do need more cialis and finasteride . [doctor] okay . [patient] i would prefer the paper prescription . [doctor] for all of them ? [patient] sure . [doctor] all right , will do . i'm gon na get your prescriptions . [patient] okay , thank you .

ASSESSMENT

• Hypogonadism.

PLAN

I recommend maintaining current management. The patient’s last testosterone levels were greater than 1500 ng/dL, although this level was likely related to his recent injection. He requested an increase to his testosterone cypionate from 140 mg to 175 mg, which I denied due to his already high testosterone levels. I counseled the patient on the risks associated with high testosterone levels and Indole-3-carbinol and it’s lacking evidence to support his estrogen levels. The last time his estradiol levels were checked, they were normal; recommend annual screening.

 I provided paper prescription refills for Cialis and Finasteride.
 "


[doctor] hi , john . how are you ? [patient] hey . well , relatively speaking , okay . good to see you . [doctor] good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you . [patient] okay . [doctor] so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ? [patient] uh , i'm feeling a lot of the same pain that i had when i had kidney stones about two years ago , so i'm a little concerned . [doctor] yeah . and so wh- what side of your back is it on ? [patient] uh , honestly , it shifts . it started from the right side and it kinda moved over , and now i feel it in the left side of my back . [doctor] okay . and , um , how many days has this been going on for ? [patient] the last four days . [doctor] okay . and is ... is the pain coming and going ? [patient] um , at first it was coming and going , and then for about the last 48 hours , it's been a constant , and it's ... it's been pretty bad . [doctor] okay . and what have you taken for the pain ? [patient] tylenol , but it really does n't seem to help . [doctor] yeah . okay . and do you have any blood in your urine ? [patient] um , uh , it ... i think i do . it's kind of hard to detect , but it does look a little off-color . [doctor] okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ? [patient] um , if i'm doing something i'm ... i'm , uh , like exerting myself , like climbing the three flights of stairs to my apartment or running to catch the bus , i feel a little dizzy and a little light headed , and i ... i still feel a little bit more pain in my abdomen . [doctor] okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago . [patient] i've been pretty diligent about taking the meds . i ... i wan na make sure i stay on top of that , so i've been pretty good with that . [doctor] okay , so no issues with the migraine ? [patient] none whatsoever . [doctor] okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes . [patient] yeah , i've been pretty good with the diet , but with the pain i have been having, it has been easier to call and have something delivered. so i have been ordering a lot of take-out and fast food that can be delivered to my door so i don't have to go out and up and down the steps to get it myself. but other than that , it's been pretty good . [doctor] okay . are you staying hydrated ? [patient] yes . [doctor] okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ? [patient] i have some body aches because i think i'm ... i'm favoring , um , my back when i'm walking because of the pain , like i kinda feel it in my muscles , but not out of the ordinary and not surprised 'cause i remember that from two years ago . [doctor] okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , dragon ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ? [patient] sure . [doctor] okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that . [patient] mm-hmm . [doctor] um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ? [patient] sure . [doctor] hey , dragon ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one- [patient] mm-hmm . [doctor] . of the stones . okay ? hey , dragon . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ? [patient] okay . [doctor] so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ? [patient] mm-hmm . [doctor] and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ? [patient] okay . [doctor] hey , dragon ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that . [patient] yes , i am . [doctor] for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ? [patient] actually , i do need a refill . [doctor] okay . hey , dragon ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so . [patient] perfect . [doctor] if your symptoms worsen , just give me a call , okay ? [patient] you got it . [doctor] take care . [patient] thank you . [doctor] hey ... hey , dragon ? finalize the note .

ASSESSMENT AND PLAN

Mr. John Perry is a 61-year-old male with a past medical history significant for kidney stones, migraines, and gastroesophageal reflux, who presents with back pain.

 Kidney stones.
 • Medical Reasoning: He is experiencing pain in his back that is similar to his previous kidney stone pain. His recent abdominal x-ray demonstrates what appears to be a recurrent kidney stone.
 • Additional Testing: I have ordered a CT scan of the abdomen and pelvis without contrast.
 • Medical Treatment: We will start him on Ultram 50 mg as needed every 6 hours for pain.
 • Patient Education and Counseling: I advised the patient to stay well hydrated and to strain his urine.

 Migraines.
 • Medical Reasoning: He has been compliant with Imitrex and is doing well at this time.
 • Medical Treatment: Continue Imitrex.

 Reflux.
 • Medical Reasoning: This is typically well-controlled with dietary modifications.
 • Medical Treatment: Continue with Protonix 40 mg daily. A refill was provided.


[doctor] next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri . [doctor] hello , how are you doing today ? [patient_guest] we're okay , thank you . [doctor] that's good to hear . so , how many days has randy been feeling sick ? [patient_guest] well , i would say it started around supper time last night . [doctor] last night , okay , and what's been going on ? [patient_guest] well , he started to get a runny nose . [doctor] okay , and is he stuffy too ? [patient_guest] yeah . yeah . [doctor] okay , and have you noticed , is his mucous clear right now ? [patient_guest] it is , it is right now , yes . [doctor] okay . and , does he also have a cough ? [patient_guest] yes , but it's not barky . [doctor] and does he act like he has a sore throat or is he pulling on his ears ? [patient_guest] well , i know he's been pulling on his ears , yeah . [doctor] okay . [patient_guest] you know , he also , he's also been going crazy rubbing at his nose too . [doctor] okay . and , any fever you've noticed ? [patient_guest] i checked his rectal temperature and it was 100.3 . [doctor] okay . so , a little bit of a low-grade fever there , definitely . and , how was his appetite ? did he eat last night ? [patient_guest] yes , he did . yeah . [doctor] and how about this morning ? did he eat his breakfast ? [patient_guest] uh , this morning he ate about seven ounces from the bottle . [doctor] okay . [patient_guest] and then he got another bottle , and he barely ate that . um , i offered him cereal and he would n't eat that either . [doctor] okay . [patient_guest] so , he varies i guess . [doctor] how is his energy ? does he seem like he wants to take more naps , or does he have pretty good energy ? [patient_guest] mmm , it seems like he's irritable . [doctor] irritable because he is n't feeling good ? [patient_guest] yeah . he is energetic , but it seems like he ca n't go to sleep , like , he's fighting it really hard . [doctor] okay , and just for the chart , is there anyone , anybody else exposed to him who has been sick ? [patient_guest] yes , his older sister's been sick . [doctor] thank you . [patient_guest] we also had a play date with my nephew , who i learned later had a sinus infection . [doctor] and what medication have you tried for him ? anything at all ? [patient_guest] um , i've been doing the saline mist in his nose . [doctor] good , good . that's a good choice . [patient_guest] i did give him tylenol really early this morning because he was warm when i took the sleeper off of him , and we had the ac on in the house , but his whole body was sweating . [doctor] i see . and , any other medications ? [patient_guest] we did put some baby vick's on his feet last night to try and help him breathe . and , i also used the humidifier . [doctor] okay . that's good . [patient_guest] okay . okay . [doctor] so , there was another thing i wanted to bring up since we're here . it appears that his cradle cap has gotten a little worse . what are you using on it ? [patient_guest] i've been using the cradle cap brush , and then i use regular aveno shampoo . [doctor] is it a dandruff shampoo ? [patient_guest] no , i do n't think so . [doctor] okay , thank you . well , let's complete his exam and then we'll talk about the next steps . [patient_guest] okay , sounds good . [doctor] can you take a big breath randy . [patient_guest] where's mama ? [doctor] do n't forget to breathe little one . okay . let's try the front too . [patient_guest] yeah , it's okay buddy . [doctor] excellent . he's doing excellent . next let's- let's check out those ears . [patient_guest] okay . [doctor] let's try to make sure you do n't tip all the way over . [patient_guest] dino , you're doing so good . [doctor] all right . ears look okay . we're going to slide you forward so you do n't bump your head when i lay you down . [patient_guest] hey , you're- hey you're okay . you're okay . [doctor] okay , you can go ahead and sit him back up if you like . [patient_guest] all right . thank you . [doctor] all right . so , he's just kind of getting started with this , and i think we're seeing something viral right now . often sinus infections will start out as a virus and then will become bacterial infections if left alone and does n't go away . but , i do n't think he needs any antibiotics , at least not at this point in time . um , keep up with the fluids , rest , and i would watch him very carefully for a barking cough . if he does get a barky cough , then that tends to be a little bit more significant and a little more severe . so , if he develops a barky cough , i want you to give him a half a teaspoon of his sister's medicine . [doctor] you know , i'm almost tempted to give you some of the medicine because they're probably sharing the same virus . [patient_guest] okay . [doctor] actually , i will . i'll go ahead and just give you some as well . [patient_guest] okay . okay . [doctor] but , if he does n't become barky , you do n't have to use it . it only works for the barky cough . [patient_guest] mm-hmm , got it . [doctor] okay . we'll do the same thing with him , as long as nothing gets worse , and we'll see him back in one week . so , it wo n't get rid of a regular cough . he can use zarbee's , but use the dose for kids under a year of age . so , if you wan na get some of that , you can definitely try that for him , it can help out a little bit with the regular cough . [patient_guest] i do have a question . do you or do you not give honey to babies ? [doctor] yes , that's a great question . you do n't give honey to kids under a year , instead , you can give them agave , which is a different type of nectar . um , now you can give honey to his older sister , that is okay , but for him , it would not be very good because his stomach acid's not good enough to break down the botulism spores . so , it'd cause him harm . um , you should look at the package of say , honey nut cheerios . it says right on there to not give it to a baby . [patient_guest] okay . [doctor] now , whether that would really hurt a baby , i am unsure , but it has real honey in it . so , no honey for him , but agave is definitely fine . [patient_guest] okay . so , zarbee's for the stuffy nose . [doctor] yes , zarbee's . [patient_guest] and then you said , uh , which medicine to give him just in case ? [doctor] i'm gon na give him the same medicine as his sister , and just hang onto it , um , just to watch and see . if this was a monday and we had a whole week to watch , i would say to just call us if things got worse , um , but since , um , if it's gon na be the weekend , and things might worsen tonight or tomorrow night , i'd rather you have just what you need on hand . [patient_guest] okay . [doctor] right , does that make sense ? [patient_guest] yeah , yeah . that makes sense . [doctor] okay , great . and that way you do n't have to share , um , with his sister . [patient_guest] right , okay . [doctor] and since he's about half her size , we'll do half the dose , which is a half a teaspoon . [patient_guest] okay . will this information all be in the papers ? [doctor] yes . and so , if he ends up starting the medicine , just give him a half a teaspoon for five days . [patient_guest] okay . [doctor] yeah , that's the only thing it wo n't say is ,  as needed ,  or anything like that . [patient_guest] mm-hmm , understood , thank you . [doctor] you're welcome . [patient_guest] and the cradle cap ? [doctor] what i would do is use something like either head & shoulder's , or selsun blue , or nizoral ad . now , do n't get the extra strength stuff , just use the regular strength . um , cradle cap , it's just basically a fancy way of saying dandruff . so , those shampoos will help get rid of it . it's not an immediate thing 'cause they , um , they are all dead scales , and you still have to brush them off . so , continue to use the soft brush and some baby oil , or something that will help get the scales out , and those shampoos will actually help to prevent it as well . use it two times per week , not every day , but maybe twice a week . [doctor] so , two days between shampooing , use what you normally use any other time . and then , often , within six weeks or so , you'll notice that the-the cradle cap is just , um , not coming back anymore . but , he has to be careful because it's not ph balanced for eyes . so , just make sure when you're rinsing his hair you avoid his eyes . [patient_guest] okay . okay . [doctor] all right . and , if it keeps getting worse , definitely let us know . [patient_guest] okay . sounds good . [doctor] good . and , since they do n't have covid-19 , you can go right ahead and check out . [patient_guest] okay . and both appointments in the week ? [doctor] correct . we'll see you all then . bye randy , feel better . [patient_guest] all right , great . thank you so much . [doctor] you are welcome , and have a good rest of your day .

ASSESSMENT

• Viral infection
 • Dandruff

PLAN

Viral infection
 The patient presents with a viral infection and does not need antibiotics currently. I advised continuation of fluids, rest. Additionally, I suggested trying Zarbee’s for children under 1 years old. If a croup cough develops, the patient will receive a 0.5 teaspoon.

 I also provided counseling to the mother to avoid giving honey to the patient for his first year of life due to botulism spores.

 Dandruff
 The patient is experiencing worsening symptoms of dandruff. I recommended Head and Shoulders shampoo, Selsun Blue, or Nizoral A-D 2 times per week, combined with his usual shampoo. I counseled the mother that she should be careful not to get the shampoo in the patient eyes and to not use the extra strength shampoos. Additionally, he may also use baby oil and a soft brush on the area.


[doctor] hi russell how are you what's been going on [patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days [doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee [patient] yeah it kinda burns a little bit [doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay [patient] okay [doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you

ASSESSMENT AND PLAN

1. Acute nephrolithiasis.
 - Medical Reasoning: The patient presents with complaints of right-sided abdominal pain. His previous CT scan was reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter without evidence of hydronephrosis.
 - Medical Treatment: I have recommended that he push fluids in order to help facilitate urination to help pass the stone. He will be provided with a strainer to allow us to potentially test the stone if he is able to pass it. I have also prescribed oxycodone 5 mg every 6 to 8 hours as needed for pain. He can continue to alternate oxycodone with Tylenol. A basic metabolic panel, urinalysis, and urine culture will also be ordered.


[doctor] hi abigail how are you today [patient] hello hi nice to meet you i'm i'm doing okay [doctor] good i'm doctor sanchez and i'm gon na go ahead and take a look i saw with your notes that you've been having some knee pain yes that's that's true you know it's been going on for a while i like to run i do jogs i sign up for the 5k tack you know sometimes the marathon and i have n't been doing longer distances because [patient] when i'm running i my right knee here it just starts to ache and it's it's just to the point where i need your opinion [doctor] okay okay what have you done for it so far what makes it better what makes it worse [patient] well it used to be that when i run it ache and then i put ice on it and then it would be okay so i do ice and ibuprofen [doctor] okay okay and did you see anybody for this before coming into the office here [patient] yeah i doctor wood is my primary care provider and i talked to him about it actually over the years and this last visit he said he referred me to you [doctor] okay okay good so ice and rest makes it feel better running and and activity makes it hurt a little bit more is that correct [patient] yeah that's right [doctor] okay do you have any family history of arthritis or any of those type of immune diseases [patient] i'm trying to think no i do n't think so no [doctor] okay and do you get is it is this primarily worse in the morning or does it is it just there all the time when it comes on [patient] it actually is worse towards the end of the day [doctor] okay [patient] once i'm on my feet all day it starts to ache towards the afternoon [doctor] okay so let's go ahead and i want to do a quick examination here your blood pressure and was one twenty over sixty that's phenomenal your heart rate was fifty eight and you can tell that you're a runner with that that level of a heart rate and your respirations were fourteen so all of that looked very good there was no fever when you came in when i'm gon na just quickly listen to your heart and lungs okay those those sound good but let me get let's focus here on your lower extremities i'm i'm gon na look at your your left knee first when i move your left knee do you get any type of pain or is it just feel like normal and it's always your pain's always isolated to the right [patient] that feels that feels normal [doctor] okay okay so let me i just want you to back up here in the stretcher a little bit more and i'm just gon na do some movement of your knee any okay so i want you to push your leg out against my hand does that hurt [patient] no [doctor] okay and if you pull back does that hurt a little bit [patient] no [doctor] okay and i'm gon na move it around so when i look at the knee there is no redness there's no swelling i can appreciate a a small amount of effusion and that means that there's a little bit of fluid under the knee or in that knee's joint space and there is there is several reasons that could be now when i push on your knee does it hurt more on the inside or does it hurt more on the outside here [patient] the the right knee here hurts on the outside [doctor] okay okay and you've got a good pedal pulse so you know you can feel that and when i touch your feet you do n't have any numbness or tingling or anything like that [patient] no uh uh [doctor] okay well so what i want to tell you is that i think you have a knee sprain from overuse and we see that sometimes in runners now unfortunately you're gon na have to take some a little bit of time off of of active running but i do n't think it will be that long until we can get you up and running again now i reviewed the x-rays that we did when you first came into the office here this morning and the joint spaces of that right knee are are well maintained i do n't see any evidence of any fracture and when compared to the left knee everything looks good so i do n't even see any signs of any arthritis that i would've been suspecting i would like you to stay on two tylenol five hundred milligrams and two ibuprofen two hundred milligram tablets and i want you to take that three times a day and that's gon na help with both the pain and the inflammation i'm also gon na order some physical therapy for your your right knee and that physical therapy will help strengthen the lower extremities and make it give you a little bit of a balance and some they'll be able to recommend good running exercises for you i do wan na follow up with you in two weeks and see if we're getting better so let's no running for two weeks and if we're we're improving then we'll move on and probably start adding some additional activity does that sound like a plan [patient] yeah that does i i was curious so i will lay off the running for now can i you know lift weights and do like my squats and and those type of exercises at the gym [doctor] yeah absolutely and and those are good exercises but i'd like you to get that first physical therapy appointment in and they'll be able to talk with you on what the best exercises are for you to do [patient] okay got it [doctor] any questions [patient] hmmm no i do n't think so [doctor] okay thank you abigail and i'd like i said stop out at the desk and we'll make an appointment for two weeks [patient] okay thanks doctor [doctor] thank you

ASSESSMENT AND PLAN

1. Right knee sprain.
 - Medical Reasoning: The patient is an avid runner and her symptoms appear to be the result of overuse.
 - Patient Education and Counseling: We discussed the nature of her diagnosis, as well as her x-ray results, in detail. I advised her that this is a common issue for runners and encouraged her to continue her strength training exercises.
 - Medical Treatment: She will take Tylenol 500 mg, 2 tablets, and ibuprofen 200 mg, 2 tablets, 3 times daily to reduce her pain and inflammation. We will also refer her to physical therapy to help strengthen her lower extremities, work on her balance, and demonstrate proper running exercises. She should avoid running for the next 2 weeks until her follow up visit, at which point we can consider adding some additional activity.