[doctor] hi , vincent . how are you ? [patient] i'm good . how about you ? [doctor] i'm good . so le- are you ready to get started ? [patient] i am . [doctor] okay . vincent is a 56-year-old male here with abnormal lab findings . so , i've heard you were in the er , vincent , and they found that you had a low hemoglobin . [patient] yup . [doctor] were you having some dizziness and some lightheadedness ? [patient] i was very lightheaded . i- i do n't know . very lightheaded . [doctor] okay . and have you noticed bleeding from anywhere ? [patient] i have not . i have n't hurt myself in quite a while . maybe a slight nick from a knife while chopping some onions , but nothing more than that . [doctor] but no blood in your stools or- [patient] no . [doctor] . anything like that ? [patient] no . [doctor] okay . and any type of weight loss or decreased appetite or night sweats ? coughs ? [patient] uh , s- slightly decreased appetite , but i wish i had some weight loss . [doctor] um , okay . and how about any abdominal pain ? fever , chills ? [patient] uh , none of that . [doctor] okay . all right . um , any nausea or vomiting ? [patient] not really . yeah . maybe a bit of nausea . [doctor] okay . [patient] i- sitting at the back of a car , that makes me nauseous at times . [doctor] okay . all right . um , well , how are you doing in terms of your knee replacement . i know you had that done last year . that's going okay ? [patient] mm , it seems okay . yeah . [doctor] okay . you're walking around without a problem ? [patient] yup , yup . just not good enough to run yet , but everything else works just fine . [doctor] all right . um , and i know a few years ago , you had , had that scare with the possible lung cancer , but then they did the biopsy and , and you've been fine . [patient] yup , yup . all good . [doctor] turned out to be benign . [patient] yup . [doctor] okay . great . all right . well , let's go ahead and do a quick physical exam . so looking at you , you do n't appear in any distress . your heart is regular . your lungs sound nice and clear . you have some tenderness to the right lower quadrant to palpation of your abdomen . your lower extremities have no edema . [doctor] um , all right . well , let's go ahead and look at your labs , okay ? [patient] yup . [doctor] hey , dragon , show me the hemoglobin . yeah , so your hemoglobin is 8.2 , which is quite low for somebody of your height and weight , so we'll have to look into that a , a little bit further . i know that they did the endoscopy in the emergency room . hey , dragon , show me the endoscope results . [doctor] good . so it looks like you had some gastritis , which is just inflammation of your stomach and they also found a slight polyp , which i know that they biopsied and the results are pending at this time . um , so , you may have had some bleeding from the gastritis . it's not usual for people to have bleeding from that . [doctor] um , okay , well , hey , dragon , show me the anemia panel . okay . [doctor] anyway , okay . well , vincent , i think , you know , in terms of , my impression of you is that you've had this newfound anemia and for that , i think that we should go ahead and put you on protonix , 40 milligrams , once a day to help with the gastritis . does that sound okay to you ? [patient] it does . you're the doctor . i do n't know what it is . [doctor] so that's just , uh , what we call a proton pump inhibitor which , uh , helps decrease the amount of acid secreted within your stomach . [patient] got it . makes sense . [doctor] hey , hey , dragon , order protonix , 40 milligrams , once a day . [doctor] and i'd like you to try to cut down on your caffeine 'cause that can also irritate your stomach . try not to take any ibuprofen and try to cut down on any alcohol intake , okay ? [patient] yup , yup . the coffee's the hard part . [doctor] yeah . it always is . how about one , one , one eight-ounce cup a day ? okay ? [patient] sure . [doctor] um , and we'll go ahead and we'll see you in a couple weeks , okay ? [patient] sure thing . [doctor] i'm going through , uh , i'll also order another , uh , cbc on you . hey , dragon , order a complete blood count . [doctor] all right . the nurse will be in soon . it's , you know , settle all that . i'll see you soon . [patient] see you . [doctor] hey , dragon , finalize the note .

ASSESSMENT AND PLAN

Vincent Young is a 56-year-old male who presents today for lab review.

 New found anemia.
 • Medical Reasoning: His hemoglobin was 8.2, which is low for his height and weight. Endoscopy from the hospital showed gastritis which could be the source of bleeding. The endoscopy also showed a polyp and a polypectomy was performed. The pathology is still pending.
 • Patient Education and Counseling: I encouraged the patient to reduce his caffeine consumption avoid NSAIDs and alcohol.
 • Additional Testing: Repeat CBC was ordered.
 • Medical Treatment: I prescribed Protonix 40 mg once a day for gastritis.


[doctor] and why is she here ? annual exam . okay . all right . hi , sarah . how are you ? [patient] good . how are you ? [doctor] i'm good . are you ready to get started ? [patient] yes , i am . [doctor] okay . so sarah is a 27-year-old female here for her annual visit . so , sarah , how have you been since the last time i saw you ? [patient] i've been doing better . um , i've been struggling with my depression , um , a bit more just because we've been trapped really inside and remotely over the past year , so i've been struggling , um , off and on with that . [doctor] okay . uh , and from looking at the notes , it looks like we've had you on , uh , prozac 20 milligrams a day . [patient] yes . [doctor] are , are you taking that ? [patient] i am taking it . i think it's just a lot has been weighing on me lately . [doctor] okay . um , and do you feel like you need an increase in your dose , or do you ... what are you thinking ? do you think that you just need to deal with some stress or you wan na try a , a different , uh , medication or ... [patient] i think the , the medication has helped me in the past , and maybe just increasing the dose might help me through this patch . [doctor] okay . all right . and , and what else has been going on with you ? i know that you've had this chronic back pain that we've been dealing with . how's that , how's that going ? [patient] uh , i've been managing it . it's still , um , here nor there . just , just keeps , um , it really bothers me when i sit for long periods of time at , at my desk at work . so i have ... it helps when i get up and move , but it gets really stiff and it hurts when i sit down for long periods of time . [doctor] okay , and do you get any numbing or tingling down your legs or any pain down leg versus the other ? [patient] a little bit of numbing , but nothing tingling or hurting down my legs . [doctor] okay , and does the , um , do those symptoms improve when you stand up or change position ? [patient] yeah , it does . [doctor] okay . all right . and any weakness in , in your legs ? [patient] no , no weakness , just , just the weird numbing . like , it's , like , almost like it's falling asleep on me . [doctor] okay . and are you able to , um , do your activities of daily living ? do you exercise , go to the store , that type of thing ? [patient] yeah , i am . it bothers me when i'm on my feet for too long and sitting too long , just the extremes of each end . [doctor] okay . and i know that you've had a coronary artery bypass grafting at the young age of 27 , so how's that going ? [patient] yeah , i had con- i had a congenital ... you know , i had a congenital artery when i was a baby , so , um , they had to do a cabg on me , um , fairly young in life , but i've been ... my heart's been doing , doing well , and arteries have been looking good . [doctor] okay . all right , well , let's go ahead and do a quick physical exam . um , so looking at you , you do n't appear in any distress . um , your neck , there's no thyroid enlargement . uh , your heart i hear a three out of six , systolic ejection murmur , uh , that's stable . your lungs otherwise sound clear . your abdomen is soft , and you do have some pain to palpation of your lumbar spine . uh , and you've had decreased flexion of your back . uh , your lower extremity strength is good , and there's no edema . so let's go ahead and look at some of your results . hey , dragon , show me the ecg . okay , so that looks basically unchanged from last year , which is really good . hey , dragon , show me the lumbar spine x-ray . hey , dragon , show me the back x-ray . great . so this looks good . that's also stable from last year . okay . so let's go ahead and , you know , my , my plan for you at this time , you know , from a chronic back pain standpoint , if you need , um , you know , some more physical therapy , and i can refer you to physical therapy to help with those symptoms that are kind of lingering . [patient] mm-hmm . [doctor] um , and we can always give you some pain medication if you , if you get some pain periodically with activity . how do you feel about that ? do you need some pain medication ? [patient] no , i think physical therapy is the right way to , way to start out on this . [doctor] okay . hey , dragon , order physical therapy referral . and then in terms of your depression , we talked about increasing your prozac , so we'll increase it from 20 milligrams to 40 milligrams . it's just one tablet once a day . [patient] okay . [doctor] um , and i'll send those to your pharmacy . does that sound okay ? [patient] that sounds great . [doctor] hey , dragon , order prozac , 40 milligrams , once a day . and then in terms of your ... the heart bypass that you've had ... let's go ahead and just order another echocardiogram for you , and i wan na continue you on the aspirin for now , okay ? [patient] okay . [doctor] hey , dragon , order an echocardiogram . hey , dragon , order aspirin 81 milligrams daily . okay , so the nurse will come in . she'll help you schedule those things , and we'll go from there , okay ? [patient] okay . [doctor] all right , take care . [patient] thank you . [doctor] hey , dragon , finalize the note .

ASSESSMENT

The patient is a 27-year-old female who presents today for an annual followup of chronic conditions.

 Chronic back pain.
 • Medical Reasoning: She is experiencing worsened pain with sitting for extended periods of time.
 • Medical Treatment: Physical therapy referral ordered. Patient would like to defer pain medication at this time.

 Depression
 • Medical Reasoning: The patient was previously doing well on Prozac 20 mg once daily but feels as though she needs a higher dose at this time.
 • Medical Treatment: Increase Prozac to 40 mg once daily. Prescription submitted.

 History of coronary artery bypass graft.
 • Medical Reasoning: She is doing well at this time. We will continue to monitor this.
 • Medical Treatment: Echocardiogram ordered. Continue aspirin 81 mg daily.
 "


[doctor] hey hi bobby how are you doing [patient] i'm doing good how are you [doctor] i'm doing fine so i understand you're here having some left or some right shoulder pain that you've had for a few weeks now [patient] yeah it was i was doing some work in my backyard and a lot of different projects going on and you know i was obviously sore all over the next couple of days but my my right shoulder just keeps on bothering me and it keeps it's just really sore and it just has n't been going away [doctor] okay so have you had ever had any pain in that shoulder before [patient] a little bit i you know i i hurt that same shoulder because it's my my dominant hand my right hand i hurt it playing baseball when i was younger [doctor] mm-hmm [patient] so i've always had a little bit issues but this is it's does n't feel like it's in the rotator cuff it's it's kinda more on the outside and it's kinda like it's more tender on the outside when i raise my arm up so [doctor] okay yeah are you able to move your arm very well or not [patient] yeah there is no restriction with my arm it just i definitely feel some pain on the outside of it [doctor] okay and are you having pain all the time or just or does it come and go [patient] just whenever i move it if i'm sitting still i really do n't notice anything but whenever i move it then i can definitely feel some pain [doctor] okay how about at night is it bothering you at night also [patient] a little bit because i sleep on that side so [doctor] okay [patient] of course [doctor] okay and i may miss did you say what have you been taking for pain for that [patient] i just been taking some advil and then icing as much as i can so that's about it [doctor] okay and does that seem to help or [patient] a little bit yeah a little bit i mean it's it's still like you know sore to touch but it definitely dulls it a little bit [doctor] well sounds like you have quite a few projects going on what all what all are you doing for for your yard and [patient] i well let's see i've been putting an outdoor shower in we're extending our patio putting making some flower boxes putting down some you know for stone and all the flower beds so my wife's really put me to work i got a laundry lift [doctor] wow it sounds like a variety of projects but if you're putting down stone you're probably lifting those as well and then [patient] yeah [doctor] yeah i bet that is sore now tell me this have you experienced any numbness in your arm or your hands or [patient] no not really no numbness that i can think of [doctor] okay alright so see i'm gon na i'd like to do just a quick physical exam and i've reviewed your vitals those look good your no fever so that's good you're ninety seven . eight and your heart rate looks good at sixty two respirations sixteen your blood pressures one sixteen over eighty four that looks fine your oxygen saturation is real good at ninety nine percent so that all looks good so let's take a look at your left at your right shoulder so you have limited active and passive range of motion and there is some tenderness at the great tuberosity of the humerus there is no tenderness at the sternoclavicular or acro acromioclavicular joints you do have a good hand grip okay and on neurovascular exam of your right arm your capillary refill is less than three seconds and your sensation to touch is intact so i've reviewed the results of your shoulder x-ray and there is no fracture so that's good so let me tell you a little bit about my assessment and plan so for your first problem the left shoulder pain your symptoms are most likely due to this rotator cuff rotator cuff tendinopathy that means you that you injured injured the tendons of the muscles that help make your shoulder muscles i think we had to go ahead and order just an mri since you have had some problems before as well to make sure there's nothing else going on with it and i also want to refer you to physical therapy for approximately six to eight weeks and so during that time continue the tylenol and if your symptoms do n't improve we can go ahead and consider a steroid injection of your shoulder which could provide some relief do you have any questions about your plan [patient] no that sounds good [doctor] okay alright yeah a lot of patients it's very successful with the physical therapy so i really hope that will do it and so we'll just start there okay [patient] sounds great [doctor] okay thanks [patient] thanks [doctor] did you have any other any other problems any other injuries that that went along with this or [patient] my both my my feet are actually really sore too i obviously have been doing a lot of other yard work so you know it's kinda it's really stiff and stuff and they you know my ankle joints as well my wife seems to think that i do n't drink enough water so it could be something along that lines but i do n't know they're kinda this they just they're really sore and stuff so i've been trying to put them up and kinda put ice on them keep them elevated and it seems to be helping out a little bit but [doctor] yeah so if you do n't feel that you did anything to injure it we might start just maybe do some epsom salts have you tried soaking your feet in epsom salts that will tend to kinda pull out what's going on in there and just help your those muscles to relax and the soreness to to go away you might try that [patient] okay that sounds like a plan that sounds good

ASSESSMENT

1. Right shoulder rotator cuff tendinopathy.
 2. Bilateral foot pain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the right shoulder to evaluate for a possible rotator cuff tear. I have also recommended that the patient attend formal physical therapy for 6 to 8 weeks. He can continue taking Tylenol as needed for pain. If his symptoms do not improve with physical therapy, I will recommend a cortisone injection.

 In regards to his bilateral feet pain, I have recommended that we treat the patient conservatively. I am recommending the patient soak his feet in an Epsom salt soak as well as elevate as needed.
 "


[doctor] kelly wood . date of birth , february 15th , 1979 . established patient here for renal ultrasound because of hematuria . urine dipstick today . negative for leukocytes , nitrates , protein , ketone , bilirubin and glucose . color yellow and clear , urobilinogen 0.2 , ph 5.5 and specific gravity 1.020 . there is a trace amount of blood in the urine and intact . renal ultrasound impression . right kidney is 10 cm in length by five centimeter wide . there are no stones , masses or hydronephrosis . the left kidney is 10.8 centimeters in length and five centimeters wide . there is a six millimeter left renal stone non-obstructing . 533 milliliters pre-void and 0 milliliters post-void . hi , mrs. wood . i see you're just finished your ultrasound . [patient] yes , ma'am . [doctor] well , it looks like you have one stone in the left kidney but it's not obstructing anything . [patient] i knew it had to be a kidney stone . i passed what looked like two small stones last week after i scheduled this appointment . and then for the past six weeks , i've had a few episodes of bright red urine the color of , like , cherry kool-aid . and last week , i was constantly having to pee and it hurt something terrible . [doctor] how bad was your pain on a scale of zero to 10 ? zero being no pain and 10 being worse , as you can imagine . [patient] um , at the time , i'd say an eight . [doctor] are you having any flank pain now or tenderness in your lower back ? [patient] no , after passing those stones , things have felt a lot better . [doctor] that's good to hear . now , it looks like you're only taking alavert 10 milligrams a day and have no drug allergies . is that correct ? [patient] that's right . [doctor] all right , let's take a look at you today . let's use my default pe . well , mrs. wood , we know that the blood in your urine was due to the kidney stones . fortunately , you passed two last week and the blood has nearly subsided . you do still have one stone in the left kidney . since it's not obstructing or causing pain , i do n't recommend any surgical intervention at this time . [patient] i'd like to know what i can do to stop getting these stones . [doctor] as we discussed last time , the formation of kidney stones can not be attributed to a particular cause . but several factors increase the risk , such as dehydration , family history , certain foods , digestive tract disease and certain medical conditions . [patient] yeah , i know i do n't drink near the amount of water that i should . i drink more mountain dew than anything . [doctor] you should drink about half of your body weight in ounces of water a day . [patient] so , if i weight 250 pounds , i should drink ? [doctor] that would be 125 ounces of water a day and you should avoid drinking sugary drinks like mountain dew . [patient] okay . is there any food i should n't eat ? [doctor] great question . you should avoid food rich in sodium oxalate and animal protein . so that would be salty , processed food because they're high in sodium . ideally , you should consume less than 1,000 milligrams of sodium a day and reduce the amount of beef , poultry , fish , and pork . [patient] what's oxalate ? [doctor] it's an organic acid found in plants , that when digested , it binds to minerals that stones are formed from . foods like spinach , chocolate , beets , rhubarb and soy products . [patient] well , i'll do whatever it takes to try to avoid getting these stones again . [doctor] great . and here's a handout that you can look over . it goes over the dietary recommendations and what to avoid . [patient] okay , good . i like to have things in writing to help me remember . [doctor] perfect . well , if you have any more questions . if you do n't have any more questions , you're all set . i wo n't need to see you back until next year , as long as you do n't have any more issues like bleeding or pain . if you do have any issues , you can always call the office sooner . and if you experience any severe pain or bright red blood in your urine , you should go to the emergency room . [patient] all right . well , let's hope we do n't have to do either of those and i see you next year . [doctor] yes , let's hope . come right this way and i'll walk you to check out . update pe abdomen . no flank pain . anti gu . normal vaginal exam . primary diagnosis is hematuria . secondary diagnosis is chronic urol ... urolithiasis . thank you . this completes mrs. wood encounter .

ASSESSMENT

• Hematuria.
 • Chronic urolithiasis.

 Mrs. Wood presents today for renal ultrasound. The patient has had recurrent episodes of hematuria over the past few months secondary to chronic urolithiasis. Mrs. Wood reports passing two small stone like structures last week. Urinalysis today was notable for only a trace amount of blood and the renal ultrasound revealed a 6 mm non-obstructing renal stone in the left kidney.

PLAN

No surgical intervention is recommended, and the patient would like to discuss urolithiasis prevention. We had a very lengthy discussion with regards to urolithiasis formation and treating the underlying cause to prevent reoccurrence and associated potential dietary factors that could be involved with urolithiasis formation.

 It is recommended that the patient maintain a healthy diet; limit salt, and animal protein. she should increase fluid consumption; adequate intake is half of her body weight in ounces of water daily and avoid sugary drinks. A copy of the dietary recommendations and avoidances was provided to the patient for reference. We will continue to monitor annually with renal ultrasound unless new symptoms develop. The patient voiced understanding and agreed with the recommended medical treatment plan.


[doctor] next patient is christine hernandez , uh , date of birth is january 13th , 1982 . [doctor] hey , miss christine , how are you doing today ? [patient] i'm good , thanks . how are you ? [doctor] i'm pretty good . so it looks like you've completed the covid vaccine , that's great . [patient] yes , i did . [doctor] anything new since your last visit ? [patient] no , i did all the tests that you had recommended me to take . i have n't been able to take the thyroid medicine , the one that you prescribed , as i'm still taking my old one . um , the price was a little high on the new one . [doctor] okay , so did ... did you try the coupon that i gave you ? [patient] i did not try the coupon , uh , there was a charge of $ 75 . [doctor] okay , well , next time that ... that coupon should help , and it should only be about $ 3 . [patient] okay , um ... i do n't have it , do you happen to have another one you can give me ? [doctor] yep , right here . [patient] wonderful , thank you so much , and ... and then the gel , they are charging me $ 100 for it . so , i do n't know if this is because it's a ... it's wal-mart , or if i should try somewhere else , or ... maybe you know how or where i can get it cheaper . [doctor] yeah , let's try something else , um ... sometimes it can be cheaper if we just prescribe you the individual ingredients of a medication , rather than the , the combined medication itself . [patient] that would be great . [doctor] so , that's clindamycin gel and benzoyl peroxide , uh , maybe by doing them separately , they could be a lot cheaper . so , that we can do . the unithroid , with the discount code , should only be about $ 9 for 90 days . [patient] okay , that would be great . yeah , they were charging me $ 75 , and i just could n't pay that . [doctor] maybe we'll try different pharmacy , as well . [patient] okay . so , do you think that my weight gain could have been the birth control that i was taking before that caused it ? [doctor] maybe . i do n't really see an endocrine cause for it , at least , so i would need to see the , the hyperandrogynism or high testosterone . or , a high dhea , to cause acne , or hair growth , or any of that stuff . but , the numbers are n't showing up out of range . [patient] okay . [doctor] i really do n't see any endocrine cause for it , like i said . your growth hormone was fine , but we definitely want to and need to treat it . um , i do n't know if we talked about maybe a little weight loss study . [patient] you mentioned the weight loss study , and you mentioned that i have some meal plans , um , that you had given me . i still have those , too . [doctor] have you tried to make any changes in the diet since the last time we spoke ? [patient] i've been trying to get better . i will start back at the gym in july , because of my contract , i had to put a hold on it until then . [doctor] okay . [patient] so , i do want to start doing that . i will be a little freer since , um , i'll be on vacation after july 8th . [doctor] okay , good . [patient] and then my cousin was telling me to ask you about cla , because it's supposed to help your metabolism . is that okay to take ? [doctor] um , i'm not sure . what is c , cla ? [patient] i'm not sure what it is , either . [doctor] okay , well , i'm unfamiliar with it , so ... [patient] okay . i also have a coworker who has a thyroid issue too , and she suggested to try chromium for weight loss . [doctor] so , that likely will not help too much . you can try either , if you really want to , but then ... it will not accept you into the weight loss study if you try those two . [patient] okay . [doctor] chromium is just a supplement and it wo n't help that much . [patient] it wo n't , okay , thank you . [doctor] it wo n't hurt ... okay , i should n't say that it wo n't hurt , but , it also wo n't help that much . so , it's up to you . [patient] okay . and so , my cousin also suggested amino acids , and that i might find them in certain foods , i guess , for my workout . [doctor] yeah . amino acids are fine , they wo n't , wo n't really help with weight loss either , but it might help , uh , you replenish , and just kind of , feel hydrated . [patient] okay . are they proteins ? um , my cousin said she had lost some weight , and has been working out every day , but she does n't work , so ... i do n't know . [doctor] yes , amino acids are what make up the protein , which is in any food you eat , with any protein . so , meats , dairy , nuts , any of that sort of thing . [patient] okay , thank you . got it . [doctor] all right . um , are you allergic to any medications ? [patient] no , not that i know of . [doctor] okay . is your s- skin pretty sensitive ? [patient] yes . [doctor] all right . [patient] um , yeah , my size , i will start getting rashes , with different products . [doctor] and have you ever tried clindamycin topical , as an antibiotic for your acne ? [patient] no , i've never tried anything for it . [doctor] okay . we might give you some of that . [patient] okay . and i also want to mention that my feet do swell up a lot . [doctor] okay . i'm ... let me take a look at that for just a moment . um , any constipation ? [patient] yes , i also do have that problem . [doctor] all right . mira- miralax will definitely help with that . [patient] okay , yes , my doctor did also recommend that . [doctor] great . all right , let's do an exam real quick . please have a seat on this table and i'll listen to your lungs and heart . [patient] okay . [doctor] all right , deep breath . all right , again . [patient] okay . [doctor] all right , sounds good . [patient] great . [doctor] let me take a look at your feet and ankles . [patient] okay . [doctor] all right , they look okay right now , certainly let your doctor know about this if it gets any worse or reoccurs . [patient] okay , i will do that . [doctor] now , let's go over your lab work . so , when you took that pill , the dexamethasone test , you passed , which means you do n't have cushing's syndrome . on that test , at least . the salivary cortisol , though , unless you did one wrong ... two of them were completely normal and one was abnormal , so , we might need to repeat that in the future . [patient] okay , that's okay . [doctor] all right , so , your cholesterol was quite high . the total cholesterol was 222 . the good cholesterol was about 44 . the bad was 153 , and it should be less than 100 . the non-hdl was about 178 , and it should be less than 130 . the good cholesterol should be over 50 , and it was 44 . so , your screen for diabetes is ... was fine . you do have a vitamin d deficiency , and , i do n't know if we started the vitamin d yet , or not . [patient] yes , we did . i- i do need to take one today , though . [doctor] okay . so , i also checked a lot of other pituitary hormones , iron levels ... everything else seemed to be pretty good , and in decent range . [patient] okay , that sounds great . so , i wanted to also show you my liver enzymes , um , because i have n't come back since then ... but i was also happy , because one of them was back to normal . [doctor] okay , great . let's see them . [patient] okay . so , the one that's 30 , that was almost 200 not so long ago . [doctor] yeah , your alt was about 128 . [patient] okay , and , and back in october was 254 . [doctor] yeah , this is much better . [patient] okay , great . and then it dropped in january , and then it dropped a little more in march , since i stopped taking the medicine in december . [doctor] okay , that's good . so ... i'm proud of you with the course of your labs , so before i forget , i'm going to , uh , just put your labs into the computer today , and i wo n't be checking your vitamin d level for some time . [patient] okay . so , with the thyroid , and the low vitamin d , does that always happen together ? [doctor] um , i do have a lot of people that have thyroid , thyroid issues and they have vitamin d deficiency . [patient] okay . [doctor] this is what i'm , um , i'm going to do . i'm going to put , print out your prescriptions , so you can shop around at the pharmacies and see if you can find better prices . [patient] okay , that way i can go ask them and try cvs . [doctor] yeah , that sounds like a plan . [patient] okay , good . so , the weight loss study that you mentioned , when does that start ? or , how does that work ? [doctor] so , we are about to start , as we just got approval last week , and we are just waiting on our paperwork so we can get started . [patient] okay , and what's involved with that ? [doctor] so , it'll involve you receiving a medication which has been used for diabetes treatment , and it works mostly in the gut on satiety , or satiety hormones . um , the most common side effects are going to be nausea , vomiting , diarrhea and constipation . they are s- uh , six arms , to the study . one is a placebo , the other ones are a , various as ... various dosages of the medication , excuse me . um , you would receive an injection once a week . also , keep in mind that most of the weight loss medications are not covered by insurance . [patient] okay . [doctor] so , it's a way of getting them , but , the odds of getting one of the arms with the medication that are in your favor , right , might be only one out of five of our hundred patients that we have on the list for the study that will receive the placebo . [patient] okay . [doctor] does that make sense ? [patient] yes , it does . [doctor] so , we do expect pretty big weight loss , because of what we learn in diabetes study . so , it's a year long , uh , process , and it's an injection once a week . you come in weekly for the first four , five weeks , i believe . and then , after that , it's once a month . you do get a stipend for partici- for participating in the study , and parking is validated , and whatever else that you need for the study . [patient] okay , do you know how much the stipend is ? [doctor] um , i will have to double check for you , and , you do n't have to be my patient , you just have to meet the criteria . so the criteria is a bmi greater than 30 , if you do n't have any other medical condition . or , a bmi greater than 27 , if you do have another medical condition , like your cholesterol . um , a bmi greater than 27 would quali- uh , qualify you . [patient] i have a friend who might be interested , and she does have diabetes . [doctor] if she has d- diabetes , then she wo n't qualify . [patient] okay , you ca n't if you ... if you have diabetes , got it . [doctor] correct . yeah , the only thing that , um , they can not have , really , is diabetes . so , either a psychiatric disease , or schizophrenia , bipolar , things like that . [patient] okay . [doctor] but , if they have hypertension , high cholesterol , things like that ... they can definitely sign up . [patient] and they can , okay . thank you for explaining that . [doctor] of course . so , do you want me to try to get you into that study ? or , would you just like to try , me to prescribe something ? it's kind of up to you . [patient] i think i'll just wait for a little bit now . [doctor] all right , sounds good . i'll give you the information for the research , it's just in my office . um , it is a different phone number , though . so then , if you're interested , just call us within a month , because i do n't know how long , uh , the , the wait will be . [patient] okay , will do . [doctor] perfect . so , let me go grab your discount card for the unithroid . um , when you go in to activate it , the instructions are on this card , and then you use your insurance ... then , show them this , and ask how much it'll cost . if it's too expensive , just let me know . [patient] i will . thank you so much for your help on that . [doctor] you're welcome . then , what i did is , i gave you a topical antibiotic , plus i gave you the benzoyl peroxide . so , the peroxide may bleach your sheets , but , you want to make sure to take it and apply it at night , so you do n't have a reaction from the sun during the day . [patient] okay , i can do that . [doctor] but , you do also want to make sure that you do n't mess up your sheets . [patient] okay , sounds good . [doctor] um , so , that's that . and then , let's see how you do on the other medications . i think this will , this will get better . in the meantime , a low-carb diet , avoid alcohol and fatty foods , and low chole- cholesterol foods . [patient] okay . [doctor] and again , once you finish your dose of vitamin d , for the vitamin d deficiency , you're gon na start with the 2000iu daily , so that you're able to maintain those levels . sound good ? [patient] yes , that sounds great . [doctor] i really think your liver enzymes are going to get better once you lose the weight , though . [patient] okay , that would be great . [doctor] since we stopped your birth control , we can try once called phexxi , which is kind of like a spermicide , basically . [patient] okay . [doctor] and you just apply it before intercourse . [patient] okay . [doctor] if you need some , uh , just let me know . [patient] okay , i will . i'll let you know . [doctor] okay , perfect . so , stay put for me now . i'm going to go see if they have discount samples , and bring you that prescription . and then , i'm going to order the labs for next time . [patient] okay , great , thank you so much . [doctor] you're welcome . [doctor] so , under the plan , under abnormal liver enzymes , they have improved since discontinuation of her birth control . under abnormal weight gain , her dexamethasone suppression test was normal . two out of three salivary cortisol tests were normal , not consistent with cushing's , and therefore we're ruling out cushing's . under her hirsutism , her androgen levels were normal . for the acne vulgaris , the epiduo was not covered , so we'll try benzoyl peroxide with clindamycin , and remove the previous information . on the hyperthyroidism , we'll print out her prescriptions . unithroid should be better priced with the discount card , and we'll repeat levels of everything before next visit . thanks .

ASSESSMENT

• Hypothyroidism.
 • Abnormal liver enzymes.
 • Abnormal weight gain.
 • Acne vulgaris
 • Vitamin D deficiency.
 • Hirsutism

PLAN

Hypothyroidism
 The patient will again attempt to initiate Unithroid. I have printed out the prescription and a discount card, which should result in a reduced price. She will contact my office if she encounters additional issues.

 Abnormal liver enzymes
 We have seen improvement since the discontinuation of Microgestin. I recommended the spermicide Phexxi for alternative birth control. The patient will also continue working on weight loss, which should additionally improve her liver enzymes.

 Abnormal weight gain
 Cushing’s Syndrome has been ruled out. I reviewed the weight loss study with the patient, she will call within a month if she is interested in participating. I advised her to follow a low carbohydrate, low cholesterol, abstain from alcohol, and reduce fatty foods diet.

 Acne vulgaris
 Epiduo was not covered and too expensive. The patient will try benzoyl peroxide and Clindamycin separately to see if the price improves.

 Vitamin D deficiency
 The patient will complete the high dose vitamin D and then should start vitamin D 2000 IU per day to maintain her levels.

 Hirsutism
 Her androgen levels were normal.


[doctor] next patient is melissa sanchez . date of birth , 9/23/1962 . mrn : 5484367 . she is being seen in office today for status post mitral valve repair done on 8/3/2020 . at her previous follow-up on 9/17 , we felt that she was doing quite well from a cardiac standpoint , and so we recommended she continue with the same medication . ecg taken on 12/26/2020 reveals atrial fibrillation with a controlled ventricular response . t-wave inversion anteriorly . compared to the previous study , there are no significant changes , and please add in the history , patient has a history of mitral regurgitation and atrial fibrillation , history of diabetes , asthma , and recurrent chest discomfort with negative cardiac workup for coronary artery disease . [doctor] ms. sanchez , it's good to see you again . [patient] yeah , it's good seeing you too dr. hughes . you look like you're doing well . [doctor] i am , thank you . you too . you're looking great . how have you been feeling ? [patient] pretty good . i'm definitely feeling better , thank goodness . i was having a rough time before surgery , um , but i think i'm overall pretty good now though . [doctor] okay . well , that's really good to hear . i'm glad . are you having any new symptoms right now ? [patient] no , not really . but , you know , i'm still getting some chest pains sometimes , and my breathing gets shallow . but , i guess i'm learning what i can and ca n't do . uh , so if i feel like that , if i'm , like , exerting myself , i slow down a bit which helps , and then when i go back to it later , i can usually finish whatever i was doing . [doctor] okay . so , it does go away though ? how long does an episode seem to last ? [patient] uh , only a few minutes i guess . then it disappears for a while . it's weird . [doctor] what is a while ? [patient] it goes away for a couple weeks . um , so when it happens , i just take the day nice and slow , i do n't push myself . [doctor] okay . so , maybe it's a couple times a month you feel this way ? [patient] yeah , just often enough for me to notice . [doctor] understood . okay . are you taking your medications regularly ? [patient] uh- . i've been trying to keep up with that . there's a lot of extra pills now , but i have a reminder app , so i do pretty well . [doctor] okay . that's great . and so , you're taking coumadin , right ? [patient] yeah , also lasix and the atenolol . [doctor] are you having any side effects from the medications at all ? [patient] not really . uh , i notice that the atenolol is making me irritable in the beginning , but i guess i've gotten used to it , does n't seem to bother me as much now . [doctor] okay . well , that sounds good . sounds like you're well on the mend . so , why do n't i start out , um , with the physical exam , and just check you out . [patient] okay . [doctor] you're going to hear me describe things in detail or repeat things as i go to reference later for my notes . [patient] okay . [doctor] okay then . i'm going to be using my status post template , ms. sanchez , please lie down on the table here and we'll get started . all right . can you turn your head to the left . head and neck no jvd detected . you can turn back now and just take a couple of deep breaths for me please . okay , that's good . and lungs have reduced breath , but auscultation and percussion are clear . okay . breath normally , i'm just going to listen to your heart . rhythm is irregularly irregular . [patient] that's a funny statement . what does that mean ? [doctor] yeah , it does sounds kind of weird , right ? it's when your heart does n't beat with the correct rhythm , and whatever rhythm it does n't have a pattern to it . so , it's part of the atrial fibrillation . [patient] wow , that sounds like a mess . [doctor] yeah , it's not ideal . but , many people have a-fib are able to keep it under control with medicine and lifestyle changes . [patient] agh , i see . that's good to know . [doctor] okay . so , s1 slightly accentuated , no s3 . i'm going to touch your belly , and does any of that hurt . [patient] nope . [doctor] how about there ? and your feet ? [patient] no , not really . [doctor] okay , great . and trace peripheral edema on extremities . all right ms. sanchez , you can sit up now . so , it looks like your heart valves are working well and you are recovering from the surgery nicely . [patient] good . [doctor] yes . we are , we looked at your ecg taken earlier today , and we are seeing the a-fib , but it's being well controlled with the medicine , and you're taking coumadin , four milligrams , lasix at four milligrams a day , and the atenolol , you're taking that every day as well , right ? [patient] yes . the 50 milligrams every day . [doctor] great . it sounds like you're well on your way to recovery . [patient] great . [doctor] so , let's continue on your current meds . i'm glad that you're figuring out what your body can handle . definitely try to keep active as that will certainly help . [patient] i'll do my best . [doctor] and that's about it . do you have any questions for me ? [patient] um , i do . when do i need to come back and get checked out ? [doctor] well , i do n't think you need to come back soon . everything from a cardio perspective is fine . so , i think let's do a followup in about six to nine months . [patient] all right , thank you . it was good to see you again dr. hughes . [doctor] you as well ms. sanchez , do take care . [patient] you too .

ASSESSMENT

• Status post mitral valve repair

 Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020.

PLAN

Continue with current medications. Coumadin 4 mg daily, Lasix 40 mg daily, and Atenolol 50 mg daily.


[patient] hi kenneth how are you the medical assistant told me that you had some knee pain yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since [doctor] okay so that was about five days ago then [patient] yeah yeah that was last weekend [doctor] last weekend okay now which knee is it [patient] it's my right knee [doctor] your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened [patient] no it just felt like something stretched and then it swelled up some afterwards [doctor] okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance [patient] i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore [doctor] yeah okay and have you ever injured this knee before [patient] no that was the first time [doctor] that was the first time okay where do you have a boat what lake do you have it on lake [patient] lake martin [doctor] okay nice and so you're a frequent water skier [patient] yeah i try to go every weekend when we can [doctor] that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day [patient] no i'm not a baseball fan but i love spring and chicken time of year launds of outdoor activities nice nice i'm i'm not really a baseball fan either but my husband makes me watch the the meds all the time and they lose all the time so he is always upset so so anyway [doctor] yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked [patient] i'm taking it everyday and i check my blood pressure at home and it's been about one twenty five over eighty most of the days [doctor] nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing [patient] not that i know of it's been a good medicine for me and i do n't have any trouble with it [doctor] okay great alright and since you had this knee pain any numbing or tingling in your foot at all [patient] no just the swelling and the pain [doctor] okay and what have you taken for the pain [patient] i i took some aleve twice a day some over the counter aleve twice a day [doctor] okay and [patient] putting a cold pack on it [doctor] okay and has that helped at all [patient] yeah that's helped a fair amount it's still pretty sore though [doctor] okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here [patient] i had my tonsils out [doctor] okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a really good job managing your blood pressure your blood pressure is up is about one twenty over seventy seven today here in the office and that's with you probably in a little bit of pain so that's good and on your neck exam i do n't appreciate any lymphadenopathy on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are clear to auscultation bilaterally on your musculoskeletal exam on your right knee i do appreciate some ecchymosis some edema there is an effusion present does it hurt when i press [patient] yeah that's sore [doctor] okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt [patient] yeah do n't do that anymore [doctor] alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you essentially i agree with you you had quite quite an injury to your knee and you do have a little bit of fluid in your knee there and just some inflammation which i think we need to talk about okay so i wan na go ahead and just talk a little bit about you know my assessment and my plan for you so for your first problem of your right knee pain i do believe you have what we call a a medial collateral ligament strain you know i wan na go ahead and just order an x-ray of your right knee just to make sure that we're not missing any broken bones which i do n't think we are but what's good about this particular injury is that people typically heal quite well from this and they typically do n't need surgery we can just go ahead and refer you to physical therapy to to strengthen those muscles around your knee so that you do n't have another injury and i wan na go ahead and just prescribe meloxicam fifteen milligrams once a day and that will help take down the swelling and help with some of the pain and you only have to take it once a day and it wo n't really cause any upset stomach or anything like that do you have any questions about that [patient] yeah if i start that medicine today am i going to be able to ski tomorrow because we got a a big weekend plan [doctor] i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we have the results of the x-ray and that type of thing okay for your second problem of your hypertension i wan na just go ahead and continue on lisinopril twenty milligrams a day i wan na just go ahead and order an a lipid panel just to make sure everything is okay from that standpoint and then i'm just looking through your health record and it looks like you're due for a tetanus shot so we'll go ahead and just give you a a tetanus shot for a from a health maintenance perspective any other questions [patient] i think so sounds like a good plan to me [doctor] okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye [patient] thank you

ASSESSMENT AND PLAN

1. Right knee pain.
 - Medical Reasoning: Based on the patient's symptoms and exam, I believe he has a medial collateral ligament strain.
 - Patient Education and Counseling: We discussed the nature of this injury as well as the expected recovery outcome. He was advised surgery is typically not needed and that physical therapy will be beneficial for strengthening to prevent future injuries. He was also counseled to rest his knee until we at least receive his x-ray results in order to prevent further injury and to allow for a quicker recovery.
 - Medical Treatment: X-ray of the right knee was ordered for further evaluation. Referral to physical therapy was provided for strengthening. A prescription for meloxicam 15 mg once a day for pain and swelling was also provided.

 2. Hypertension.
 - Medical Reasoning: The patient is doing well on his current medication regimen. He is monitoring his blood pressure at home and has not had any elevated readings.
 - Medical Treatment: He will continue taking lisinopril 20 mg a day. Lipid panel was ordered today.

 3. Health Maintenance.
 - Patient Education and Counseling: I advised the patient that his records indicate that he is due for a tetanus vaccine.
 - Medical Treatment: The patient will receive his tetanus vaccine in office today.


[doctor] hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened [patient] yeah i was in a car crash [doctor] wow okay when was that [patient] well which car crash [doctor] okay so multiple car crashes alright so let's see if we can how many let's start [patient] my therapist said well my well actually my mother said i should go see the therapist and the therapist said i should see the lawyer but my neck's hurting [doctor] okay so i'm glad that you know you're getting some advice and so let's let's talk about this neck pain how many car crashes have we had recently [patient] well the ones that are my fault or all of them [doctor] all of them [patient] i was fine after the second crash although i was in therapy for a few months and then after the third crash i had surgery but i was fine until this crash [doctor] okay the most recent crash when was that [patient] that's when i was coming home from the pain clinic because my neck hurt and my back hurt but that was in february [doctor] okay alright so we had a car crash in february [patient] what year it was which february it was [doctor] okay so let's let's try with this one see what happens hopefully you remember i need you to start writing down these car crashes that this is becoming a thing but you know it's okay so let's let's say maybe you had a [patient] you're not judging me are you [doctor] no there's no judgment here whatsoever i want to make sure that i'm giving you the best advise possible and in order to do that i need the most information that you can provide me makes sense [patient] yes [doctor] alright so we're gon na say hope maybe that you had a car crash and we can verify this in february of this year and you've been experiencing some neck pain since then right [patient] yes [doctor] okay alright on a scale of one to ten what ten is your arm is being cut off by a chainsaw severe how bad is your pain [patient] twelve [doctor] okay terrible pain now i know you mentioned you had previous car crashes and you've been to therapy has anyone prescribed you any medication it's you said you went to a pain clinic yes [patient] well they had prescribed it recently i was i was on fentanyl [doctor] oh [patient] i have n't gotten a prescription for several weeks [doctor] okay alright and so we will be able to check on that when you take your medication so before you take your medication rather like are you able to move like are you experiencing any stiffness [patient] yes but it hurts [doctor] okay it hurts what kind of pain is it sharp is it dull is it throbbing [patient] it's the sharp incapacitating pain i ca n't work [doctor] wow okay are you having any headaches [patient] of course [doctor] any dizziness [patient] just sometimes [doctor] any visual disturbances is it hard to like are you [patient] not recently no [doctor] okay alright any numbness [patient] yes [doctor] where [patient] my left arm and my right leg [doctor] okay any spasms [patient] of course [doctor] okay where [patient] my body hurts i told you my neck hurts [doctor] okay so i no i'm absolutely i wan na make sure that we are gon na give you the medication that works like the best for you so i'm sorry if these questions seem like frustrating i would just wan na make sure that i understand what the problem is so [patient] i saw pamela and doctor collins's office she's much nicer than you know [doctor] i mean okay so you know what like maybe maybe pamela would be better like we could maybe talk talk about a referral if that would make you more comfortable [patient] my lawyer told me to come here [doctor] then you're stuck with me okay i'm so sorry but here it's we're gon na try and make it as good as possible alright so last thing i do wan na do my physical exam alright and i need you to let me know as as much as you as much as you can verbalize right so when i push here in the middle of your neck on top of the bone does it hurt [patient] yes yes [doctor] okay alright sorry what about on the side does that hurt [patient] yes [doctor] okay so pain on palpation both on the bony process and on the muscle can you move your neck from side to side can you move your neck can you swive it side to side no no alright so i'm i'm seeing i'm seeing some range of movement moderate range of movement that's fine okay i so when can you bend your neck forward that that's your whole body just just the neck are you capable of bending up [patient] really hurts it really hurts [doctor] okay it really hurts to bend forward and backwards okay alright so i'm just gon na make a little note here i do n't i do n't see any bruising i'm not noticing any swelling there is i i do n't see any laceration what [patient] just sometimes it bruises [doctor] okay sometimes alright that's fine i i just i'm not seeing one here today so that's okay alright so with that being said i do wan na ask have you been experiencing any fatigue are you tired [patient] well since the accident yes [doctor] okay alright just making sure okay so this is what this is my assessment and plan this is what we are gon na do i want to be able to like we had you do an x-ray before you came in here and looking at it i'm not noticing any fracture that's a really good sign considering how many car accidents we've been in lately [patient] it hurts it hurts [doctor] absolutely no i we're gon na address the pain so for my first so looking at your imaging results though i'm not seeing a fracture that's a great sign so for your first diagnosis i'm gon na say that you have what is called a neck sprain that [patient] thinking are are you saying i'm thinking [doctor] no not by any means i am saying [patient] pain i have a lot of pain [doctor] yes and your pain can be explained by multiple things but thankfully it's not a broken neck is that okay [patient] yes [doctor] alright so what we are gon na do when we are gon na like try and treat this as conservatively as possible [patient] said it might be broken [doctor] what [patient] pamela said it might be broken [doctor] if pamela said it's broken then you know what this is what we're gon na do we're gon na order something called a ct that's gon na give us even nope you know what let's upgrade to an mri it's gon na give us the most thorough image of everything that's going on the heart and the soft tissues is that gon na is that so that way we can really get a good image of what's happening inside right [patient] okay because what the lawyer said i needed was an mri [doctor] not a problem we're we're gon na make your lawyer happy next step we are going to try working like from the outside in so i do need you to work on getting like you're you're saying you've seen some bruising and some swelling yourself so i want you to put ice on that whenever you're experiencing that in the moment when you wake up i want you to do your best to just like i'm gon na give you some exercises on the sheet and i want you to roll through these exercises every morning right to just get some like movement and like free frenosive movement back into your neck i also wan na put you on a couple medications now i know that you said you were on fentanyl before that's a bit extreme and i i want i i i wan na like monitor this a little more conservatively so what we're gon na start with is something called robaxin [patient] hurts a lot if i do n't get more fentanyl [doctor] you know we can refer you to pain medicine if it really is getting that complicated but for this current period we're gon na put you on some robaxin it's gon na be fifteen hundred milligrams and you're gon na take that six to eight hours every six to eight hours and that really should help kinda relax the muscles in the area take off some of that tension and really help with that pain if you're noticing that the robaxin still is n't helping maybe then we can start we can like start using like a heat pad or maybe some icyhot the biofreeze is a really good one to kinda help with that and then we will refer you to physical therapy i think with the mri we can start evaluating maybe some additional steps so rather than you having to like take that fentanyl because i do n't want you to be in danger right like people i do n't want you to get rubbed so what we could explore are local injections right and we can refer you to pain medication and see about like locally injecting the area and that should be able to help you out hopefully with this [patient] i ca n't go to work like this [doctor] okay so if it's if it's that bad let's wait for the mri result we're gon na give you off for work because you know you ca n't move and we'll see what the mri says about what whether or not we can get you like true local injections in the moment is that alright for now [patient] yeah [doctor] okay okay any other questions [patient] not right now [doctor] alright

ASSESSMENT

Neck sprain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I recommended an MRI for further evaluation. I have also prescribed the patient Robaxin 1500 mg every 6 to 8 hours to treat his pain. I have also advised him to utilize ice, a heating pad, IcyHot, or Biofreeze on his neck as needed. I have also provided him with a home exercise program to work on his range of motion. I advised the patient that he will not be able to work until we have the MRI results.


[doctor] well hello christina so how are you doing i was notified you were in the hospital for some heart failure what happened [patient] well i'm doing better now but i just started having problems that my ankles were swelling and could n't get them to go down even when i went to bed and could n't breathe very good had to get propped up in bed so i could breathe at night and so i just really got to feeling bad i called my friend diane and she said i probably ought to call nine one one since i was having a hard time talking and so i called nine one one and they sent out an ambulance and they took me into the er on the it was quite an experience [doctor] yeah [patient] having an ambulance ride and and i've never done that before so not an experience i wan na do again either [doctor] i'm sure you do n't yeah i see that your blood pressure was high also it was two hundred over ninety have you been [patient] yeah i guess is that really high [doctor] yeah that's [patient] i feel really bad [doctor] yeah that's pretty high are you taking your medications or you missing some doses [patient] i do n't know i might miss one now but i try to take them all time [doctor] yeah yeah you really need to take them very consistently now you also said you were watching your diet did you did you have some slips with that you said your ankles were swelling [patient] no i yeah i do i like to i like to eat [doctor] are you eating a lot of salty foods and pizza or [patient] i like potato chips [doctor] yeah [patient] i like the salt and vinegar potato chips they're really good so [doctor] well so do you do you go out to eat a lot or do you where you where where are you eating those potato chips or is that just the home snacking or [patient] that's home snacking i buy the the the the brand name salt and vinitive because brand wo n't taste real good but the the brand names really tastes good [doctor] oh [patient] so i eat those probably everyday [doctor] goodness well you know you we need to probably stop eating those now [patient] yeah well i hate to hate to give those up but i guess i might have to [doctor] well since you've been in the hospital and and they've helped you out with some with all that how are you feeling now [patient] well i'm i'm doing better [doctor] mm-hmm and they [patient] i do n't do n't have quite as much shortness of breath i think maybe getting up and walking a little more is helping [doctor] and they gave you a water pill and is that is that helping is that making you pee a lot [patient] yeah yeah i have almost incontinence so [doctor] goodness [patient] yes that's not very pleasant at all [doctor] and so they added another blood pressure medication also how are you doing with that are you feeling a little bit better [patient] yeah i think so [doctor] okay [patient] if i can remember to take the pills [doctor] yeah [patient] that seems to be a sticky point [doctor] well a a pill box or maybe setting an alarm on your phone might really help [patient] okay i'll i'll give that a try anything that will help [doctor] yeah okay well that's good to hear so now have you bought a blood pressure cuff to have at home now [patient] yes i already had one but i very failed if i ever used it [doctor] okay [patient] but [doctor] got it [patient] i'll i'll try to use it everyday now [doctor] okay and you might even just keep a log of what your blood pressures are and when it's up think about you know what you've eaten if you've done something different because that may help you to figure out what you need to cut back on or how you might need to change your your eating habits a little bit so [patient] okay okay [doctor] have you been short of breath or any problems sleeping since you've been home [patient] no i've been sleeping like a log [doctor] okay good alright have you had any chest pain [patient] no no chest pain [doctor] okay alright well let's do a quick physical exam here so your vital signs your blood pressure looks pretty good today at one twenty eight over seventy two your temperature is ninety eight . seven and your heart rate is seventy two your respirations are eighteen your oxygen saturation looks pretty good at at ninety six percent okay now on your neck exam there is no jugular venous distention on your heart exam i appreciate a two over six systolic ejection murmur which i've heard before and so it's stable and your lungs are clear bilaterally and your lower extremities show just trace edema now now we since we did the echocardiogram i reviewed those results and it does show a preserved ef of fifty five percent abnormal diastolic filling and mild-to-moderate mitral regurgitation so let me tell you a little bit about my assessment and plan so for your first problem for your congestive heart failure it sounds like this was caused by dietary indiscretion and some uncontrolled hypertension so i want you to continue on your bumex two milligrams once daily continue to watch your diet and avoid salty foods might try keeping that log we talked about with your blood pressures and what you've eaten if if your blood pressure seems a little high also weigh yourself daily and call me if you gain three pounds in two days okay [patient] okay [doctor] and i also want you to see a nutritionist to give you some education about what foods you can eat okay now for your second problem for i know this sounds like this is just for you and so for your second problem for your hypertension i want you to continue on the cozaar one hundred milligrams daily continue on the norvasc five milligrams once daily also and i'm going to order a renal artery ultrasound just to be sure we're not missing anything and then like maybe you know some renal artery stenosis or something and so so for your third problem for your kidney disease i wan na get some more labs to make sure you tolerate this the new medications and then i'll see you again in three months do you have any questions [patient] no i do n't think so not today [doctor] alright it's good to see you and i hope we'll just keep getting you feeling better [patient] okay

ASSESSMENT AND PLAN

1. Congestive heart failure.
 - Medical Reasoning: This appears to have been caused by dietary indiscretion and uncontrolled hypertension.
 - Patient Education and Counseling: I encouraged the patient to continue making dietary modifications, including limiting her sodium intake. She could try keeping a food diary, as previously discussed, to log her diet and associated blood pressure readings. I also advised her to monitor her weight daily and contact me if she gains 3 pounds in 2 days.
 - Medical Treatment: Continue with Bumex 2 mg once daily. Referral placed for consult with a nutritionist for education and recommendations regarding her diet.

 2. Hypertension.
 - Medical Reasoning: This has been poorly controlled due to inconsistent compliance with medication and dietary indiscretion.
 - Patient Education and Counseling: We discussed dietary modifications as noted above.
 - Medical Treatment: She can continue on Cozaar 100 mg daily and Norvasc 5 mg once daily. Renal artery ultrasound ordered to rule out any issues such as renal artery stenosis.

 3. Kidney disease.
 - Medical Treatment: Labs will be ordered to assess her response to new medications.


[doctor] alright so how're you doing today angela [patient] i'm doing pretty well [doctor] alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on with your kidneys you as what how long ago have you been feeling pain and and how's all that [patient] pain's been up and down i went to the emergency room last week but now i think i'm doing a little bit better [doctor] okay so the case of kidney stones so have you had you said you've had them in the past and how often would you say [patient] i do n't know i this is probably like my seventh or eighth kidney stone [doctor] seven or eight kidney stones so do you think you passed it yet or is it still in the [patient] i think this one passed yeah [doctor] this one passed how long would you say it took to [patient] well i went last week and then i think it passed about three days ago [doctor] okay so are you still noticing any blood in your urine [patient] no no more blood [doctor] alright are you still having pain [patient] nope [doctor] yeah [patient] the pain's gone [doctor] okay that that's that's that's really good did they do anything for you at the hospital giving you any medications [patient] they gave me some pain medicine [doctor] okay do you remember what it was [patient] i think it was percocet [doctor] okay well that's good i'm very glad to see that you were able to pass that stone have you seen a urologist before about this [patient] i have n't seen one in a while but yes i saw someone maybe a year ago [doctor] okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well [patient] okay [doctor] so i also see you're here for you have a past medical history of of hypertension and when you came in today your blood pressure was a little bit high it was a one fifty over ninety i'm reading here in your chart you're on two point five of norvasc [patient] hmmm [doctor] now have you been taking that regularly [patient] i have but at home my blood pressure is always great [doctor] okay maybe you have a little white coat syndrome some of my patients do have it i have it myself and i'm a provider so i definitely understand yeah i know we we talked about last time you getting a blood pressure cuff and taking those about two to three times a week so what have those readings been i'm usually like one thirty to one forty over sixty to seventy [patient] okay [doctor] that's that's that's not too bad i think when you first came in you were around like one eighty so it seems to be that that norvasc is is working for you how about your diet i know you were having a little issue eating some fast food and and cakes and cookies and have you been able to get that under control [patient] yeah it's hard to give up the fast food altogether because it's a lot of on the go you know [doctor] okay so do you think you would be able to get that under control by yourself or would you do you think you would need help with that maybe a dietitian be able to help you out [patient] yeah i do n't know i do n't know if i can make another appointment i just add to the extra [doctor] okay [patient] less time to make food so [doctor] yeah yeah definitely understand [patient] mm-hmm [doctor] alright yeah so i mean that's one thing we just got ta work one is your diet we try to keep you at least just twenty three hundred milligrams or less of sodium per day i know that's hard for a lot of salads and stuff i know it's hard for lot of people especially with all like the the prepackage foods we have around today so that's definitely something we we should work on [patient] mm-hmm [doctor] so let's also look here you have a history of diabetes and so you're on that five hundred milligrams of metformin daily now have you been taking that as well [patient] yeah i take my metformin [doctor] okay [patient] yeah [doctor] so what have your blood sugars been running daily [patient] well i do n't check it very often [doctor] okay [patient] but i think they've been pretty good [doctor] okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam on you before i do just wan na make sure are you having any chest pain today [patient] no [doctor] alright any any belly pain [patient] no [doctor] alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na just press here in your abdomen because that you did have those kidney stones does that hurt [patient] no [doctor] alright i'm gon na press here on your back [patient] no pain [doctor] okay so on your abdomen exam of your abdomen i'm showing no tenderness to palpation of the abdomen or tenderness of the the cva either on the right side so that that's good i think that's pretty much cleared up so let's we'll talk a little bit about my assessment and plan for you and so my assessment you you did have the those kidney stones but i i think they are passed this time but i do want to get a couple of labs so we'll get a urinalysis [patient] okay [doctor] alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology [patient] okay [doctor] because you do keep having these all the time and so maybe there's something else going wrong and so they can help get that under control [patient] can i see doctor harris [doctor] of course yeah we can we can get you that road to doctor harris and [patient] he's not like [doctor] he's great he's he's he he he's great i've heard he does really good work so that'll be good so for the hypertension you seem to be doing well on the two . five of norvasc so we are not gon na make any changes to that do you need any refills right now [patient] no usually the pharmacy just sends them through when i call [doctor] okay great so we we wo n't we gave you refills with that i do wan na give you a consult to nutrition [patient] okay [doctor] just to help you with that diet [patient] okay [doctor] because i think that's a major factor of us eventually getting you off of all medications [patient] hmmm [doctor] and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal [patient] okay [doctor] just to gauge where you are so you can tell how much food you should actually be be eating [patient] okay [doctor] alright [patient] i can try that [doctor] so how does that that sound [patient] that sounds like a plan when should i come back and see you [doctor] so you can you can come back in three months and we'll check up again i forgot you did tell me last time that you were having some issues with insomnia [patient] hmmm [doctor] how is that going for you is it still happening [patient] i mean sometimes i stay awake just kinda worrying about things but but i've tried some meditation apps and that helps [doctor] okay alright and i know we talked a little bit before about practicing proper sleep hygiene you know just making sure that all of your electronics are off you know dark room [patient] yeah [doctor] cool room have you been doing that [patient] well i do like to sleep with the tv on and my phone is right by my bed because i never know if someone's gon na call me you know [doctor] yeah i i know i'm like apple i do n't know if you have an iphone or not but i know apple has this the the sleep mode now do that disturbance so you put that on [patient] it's a good idea [doctor] interrupt you [patient] yeah [doctor] okay have you tried taking melatonin to sleep [patient] i used it a couple times but but it did n't seem to help that much [doctor] okay how about i do n't think i've prescribed you anything yet do you think you would need anything [patient] hmmm i do n't really wan na take any sleeping pills [doctor] okay that's understandable alright so for the last issue for the insomnia i'm just gon na have you take ten milligrams of melatonin as needed [patient] okay [doctor] and just try i guess the best as possible to practice the proper sleep hygiene so you can get to sleep at night and and feel pretty rested [patient] okay [doctor] alright [patient] mm-hmm [doctor] so do you have anything any other questions for me [patient] no that's all [doctor] alright so we will see you in three months [patient] okay sounds good [doctor] alright [patient] like

ASSESSMENT AND PLAN

1. Kidney stones.
 - Medical Reasoning: Patient recently experience an episode of kidney stones which is her 7th or 8th episode. Based on the patient's symptoms and exam today, I think she has likely passed her kidney stones.
 - Patient Education and Counseling: I advised the patient that we will obtain further testing, however, based on her recurrent episodes a referral to urology is necessary.
 - Medical Treatment: Urine culture and urinalysis were ordered. She will be referred to Dr. Harris in urology.

 2. Hypertension.
 - Medical Reasoning: Patient is currently stable and doing well on Norvasc 2.5 mg.
 - Medical Treatment: Continue Norvasc 2.5 mg. Referral to nutrition provided.

 3. Diabetes.
 - Medical Reasoning: Patient is currently stable and compliant with her metformin.
 - Patient Education and Counseling: She was advised to start checking her blood sugar prior to every meal.
 - Medical Treatment: Continue metformin 500 mg daily. Start daily blood sugar monitoring before each meal.

 4. Insomnia.
 - Medical Reasoning: The patient has a history of insomnia.
 - Patient Education and Counseling: We discussed proper sleep hygiene.
 - Medical Treatment: I have recommended she take 10 mg of melatonin as needed.


[doctor] hi , cheryl . how are you ? [patient] i'm doing well . how are you ? [doctor] i'm doing well . so i know the nurse told you a little bit about dax . i'd like to tell dax about you . [patient] okay . [doctor] cheryl is a 34-year-old female with a past medical history significant for hypertension , who presents today with back pain . cheryl , what happened to your back ? [patient] so i've been walking a lot lately . i've been walking to ... 30 minutes to an hour or so a day . and all of a sudden , um , when i was walking , my , um , back just kind of seized up on me . and i do n't really know what it was . maybe i was going a little bit faster . but it just all kind of clenched . [doctor] okay . so you felt like , maybe like a spasm or something like that ? [patient] yeah . [doctor] okay . and how many days ago was that ? [patient] that was about six days ago now . [doctor] okay . and what have you taken for the pain ? [patient] i've been taking ibuprofen . um , and then i've been putting some heat on it . but it's still pretty stiff . [doctor] okay . all right . um , and did you have any trauma before that happened ? were you doing anything strenuous like crossfit or lifting boxes or anything like that before you went for , for the walk ? [patient] i have been lifting more , um , probably around three times a week . so i do n't know if it was because i was doing deadlifts that day and then walked . [doctor] okay . [patient] um , maybe i was using my back more than my legs . [doctor] okay . all right . and was it any particular area in your back ? was it the lower back ? [patient] yeah , it was . [doctor] okay . on one side versus the other ? [patient] um , kind of both equally . [doctor] okay . all right . and any numbing or tingling in your legs or your feet ? [patient] no , i have n't felt anything like that . [doctor] okay . any weakness in your lower extremities ? [patient] no . [doctor] okay . all right . and then in terms of your blood pressure , how are you doing ? [patient] so i got that cuff that you suggested the ... our ... the last visit , and i've been doing readings at home . and that's been looking great , too . i've been watching my diet . again , my boyfriend's been great and dieting with me so i do n't have to do it alone . and everything's been good . [doctor] okay . excellent . and you're taking the lisinopril ? [patient] yes . [doctor] okay . wonderful . okay . so i know you did a review of systems sheet with the nurse , and i know you endorse , you know , this back pain . um , do you have any other symptoms ? fever , chills , congestion , cough , chest pain , shortness of breath ? [patient] i have a little bit of nasal congestion , but that's just from my seasonal allergies . [doctor] okay . all right . well , let's go ahead . i want to do a quick physical exam on you . [patient] okay . [doctor] okay ? hey , dragon , show me the vital signs . so good- you know , here in the office , your vital signs look great . your blood pressure's really well controlled , which is good . so that's a good job . so i'm going to take a listen to your heart and lungs . i'm going to examine your back , and i'm going to let you know what i find . okay ? [patient] okay . [doctor] okay . all right . so on physical examination , you know , everything looks good . you know , on your heart exam , i do hear that slight two out of six systolic ejection murmur , but you've had that before . that seems stable to me . on your back exam , you do have some pain to palpation on the right lateral aspect of your lumbar spine , and you do have pain with flexion and extension as well , and you have a negative straight leg raise . so what does that mean ? so we're going to go over that . okay ? let's ... let me look at some of your results , though , first . okay ? [patient] okay . [doctor] we did an x-ray before you saw me , so let's look at that . hey , dragon , show me the back x-ray . so looking here at this x-ray of the lumbar spine , everything looks good . there's good boney alignment . there's no obvious fracture , you know , which is not surprising based on your history . okay ? [patient] hmm . [doctor] hey , dragon , show me the labs . and your labs that we did before you came in all look great . there's no elevated white blood cell count . there's no signs of infection . again , those are all really good . okay ? so let me go over with you about my assessment and my plan for you . so for your first problem , this back pain , i think you have a lumbar strain , and , you know , that might've happened , you know , lifting something or exercising . and so what i want to do is prescribe meloxicam , 15 milligrams once a day . uh , i want you ... you can ice the area , and you can also apply heat sometimes as well . um , you know , i'm going to refer you to physical therapy just to do some strengthening exercises of your back , um , because i do want you to continue to be able to work out and exercise . okay ? [patient] okay . [doctor] and for your last problem , your high blood pressure , again , everything looks great here . um , you know , i think you're doing a really good job with that as well . i want you to continue on the lisinopril , 10 milligrams a day . and then , uh , let me know if you notice any increases in your blood pressure readings . okay ? [patient] okay . [doctor] do you need a refill of the lisinopril ? [patient] yes , i do , actually . [doctor] okay . hey , dragon ? order lisinopril 10 milligrams po daily . okay . uh , so the nurse will be in soon , and she'll get you checked out . okay ? [patient] okay . [doctor] all right . hey , dragon ? finalize the note .

ASSESSMENT AND PLAN

Ms. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.

 Back pain.
 • Medical Reasoning: She experienced a spasm-like pain in her back while walking approximately 6 days ago. She has also been lifting weights recently. Her lumbar spine x-ray was unremarkable and her recent labs were normal. I believe she has a lumbar strain.
 • Medical Treatment: We will initiate meloxicam 15 mg once daily.
 • Specialist Referrals: We will refer her to physical therapy to work on strengthening exercises.
 • Patient Education and Counseling: She may apply ice and heat to the area.

 Hypertension.
 • Medical Reasoning: This is well controlled with lisinopril and dietary modifications based on home monitoring.
 • Medical Treatment: She will continue lisinopril 10 mg daily. This was refilled today.
 • Patient Education and Counseling: I encouraged her to continue with home monitoring and report any elevated blood pressures to me.


[doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three nonsmile cell lung cancer who presents for follow-up during neo agit chemotherapy she was diagnosed with a four . four centimeter left upper lobe nodule biopsy was positive for adenocarcinoma molecular testing is pending at this time alright hello beverly how are you [patient] i'm good today [doctor] you're good today yeah you've been going through a lot lately i know you just had your treatment how how are your symptoms [patient] my symptoms are pretty good today i just kind of have a minimal cough and a sore throat [doctor] okay [patient] but that's all i'm feeling today [doctor] okay and how about fatigue have you been feeling more tired [patient] yes a little bit [doctor] okay and how about any nausea or vomiting [patient] no not as of today [doctor] okay and i know you were mentioning a cough before how is it as far as walking are you having any shortness of breath [patient] i have n't noticed any shortness of breath it just kind of seems to be a lingering kind of light dry cough [doctor] cough okay is it any mucus with it or is it a dry cough [patient] more dry [doctor] a dry cough okay and tell me more about this sore throat [patient] this kind of seems to be persistent comes and goes it will be worse sometimes and then others it feels better trying to drink lots of fluids [doctor] okay [patient] to see if it can it you know the dry coughing if it's part of that or what i can do [doctor] okay and when you mention drinking and eating is do you feel like anything is getting stuck there [patient] no i do n't feel like anything is getting stuck right now and i have n't been i have been eating but not as much as i normally would [doctor] okay okay alright and how are you doing as far as like just emotionally and mentally how are you doing i'm just talking a little bit about your support systems [patient] the nursing staff and the office has been very good to help you know with anything that i need as far as support so just since we are just getting started so far on the journey i do feel like i have support and mentally you know still feel strong [doctor] okay and how about with family or friends have you been able to turn to anyone [patient] i do have good family members that have been supportive and they have come to my treatment with me [doctor] okay excellent excellent and so right now you're on a combination of two different chemotherapies the cisplestan as well as the eupside and you had your last treatment just a few days ago but you're saying right now you've been able to tolerate the nausea and the fatigue [patient] yes i have n't had any nausea but you know just slight fatigue it does n't seem to be overwhelming [doctor] okay okay so we are gon na go ahead if it's okay with you and start your physical exam reviewing your vitals so vitals look good especially your oxygen especially with the chemotherapy you've been getting and the cough so your oxygen looks good so i'm happy with that so now i'm just examining your neck especially with your sore throat and i do n't appreciate any cervical lymphadenopathy and also no supraclavicular adenopathy listening to your heart you have a nice regular rate and rhythm with no murmurs that i appreciate now on your lung exam when you're taking some deep breaths i do notice some crackles in your lungs bilaterally and what that means is there is there is some faint sounds that i'm hearing which could represent some fluid there so on looking at your skin exam on your chest you do have some erythema on the anterior side of the chest on the left side and this could be related to the radiation so on your lower extremities i appreciate no edema and everything else looks good and thank you i know you did a chest x-ray before coming in so on your results for the chest x-ray it does look like you have some mild radiation pneumonitis which basically means some inflammation of the lungs most likely due to the radiation so what does this all mean so for your assessment and plan so for the first diagnosis the first problem of the lung cancer so what we're gon na do is we're gon na continue with the current regimen of your chemotherapy of the cisplacin and the etoside and we're gon na continue with your current dose of radiation at forty five grade and when that's complete we will repeat some imaging and hopefully you know the tumor will shrink down enough that we can remove it surgically okay for problem number two so the radiation pneumonitis so that's what causing that cough as well as some of the shortness of breath i know you're not experiencing it much now so what i'm gon na do for that is actually gon na prescribe you a low dose of prednisone and so that's an will help with the inflammation i'm gon na give you forty milligrams daily for five days and so hopefully that will help reduce the inflammation and so that you can continue with the radiation okay how does that sound so far [patient] that sounds great thank you [doctor] okay and then lastly for the painful swallowing that you're having so the inflammation you're having it not only in your lungs but it also in your esophagus as well so what i'm gon na do is prescribe you you're taking the the prednisone i'm also gon na give you a lidocaine swish and swallow and you can do that four times a day and so that will be able to help you so you can eat immediately after taking it and it can also help so that you can continue to take food and fluids prevent dehydration and any further weight loss [patient] great [doctor] okay any questions for me [patient] i do n't believe so at this time [doctor] okay alright so i'll see you at your next visit [patient] great thank you [doctor] you're welcome and so now just

ASSESSMENT AND PLAN

1. Stage III non-small cell lung cancer.
 - Medical Reasoning: The patient has a recent diagnosis of stage III non-small cell lung cancer. Biopsy was positive for adenocarcinoma. Molecular testing is pending at this time.
 - Medical Treatment: We are going to continue with the current regimen of combination chemotherapy consisting of Cisplatin and etoposide. We are also going to continue with her current dose of radiation at 45 Gy. Once this is complete, we will obtain repeat imaging in hopes that the tumor will decrease in size enough for surgical removal.

 2. Radiation pneumonitis.
 - Medical Reasoning: The patient is experiencing a persistent dry cough. Recent x-rays are reviewed and demonstrated evidence of mild radiation pneumonitis.
 - Patient Education and Counseling: We discussed the etiology of her dry cough is from her mild radiation pneumonitis.
 - Medical Treatment: A prescription of prednisone 40 mg daily for 5 days is provided to help with her inflammation.

 3. Painful swallowing.
 - Medical Reasoning: The patient is experiencing painful swallowing secondary to inflammation of the esophagus.
 - Patient Education and Counseling: We discussed the etiology of her painful swallowing and that a lidocaine viscous solution will be beneficial in preventing dehydration and any further weight loss.
 - Medical Treatment: A lidocaine viscous solution was provided to be performed 4 times daily.