[doctor] alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened [patient] well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then all of a sudden i'm here [doctor] hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath [patient] i did but i did n't think anything of it [doctor] sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on [patient] i have but i miss them every year and then so i think today i took one [doctor] okay alright yeah i have you on bumex cozaar and norvasc does that sound right [patient] i guess so that sounds about right [doctor] alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that [patient] i've just been eating anything honestly i try to watch it here and there but to tell you the truth i'd looks i was eating [doctor] yeah i i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or [patient] little bit of everything here and there i do lot of chips [doctor] sure [patient] they're pretty good i guess they're salty even though the light salt ones but [doctor] mm-hmm [patient] kinda whatever i can get my hands on really [doctor] okay alright how are you feeling right now [patient] i'm doing a little okay i guess i'm just out of breath a little bit but it's nothing i ca n't handle [doctor] sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those [patient] no i have n't got one yet i know i needed to get one [doctor] yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately [patient] just like i said when i was walking outside it helped a little bit but again i just walked it off [doctor] sure any problems sleeping [patient] no i sleep like a rock [doctor] good good to hear have you had any chest pain [patient] slightly here or there but i thought it was just heartburn [doctor] sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that [patient] i've been pretty good on it very once every week maybe just one [doctor] okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay [patient] that sounds good document [doctor] awesome weigh yourself daily do you have a scale at home [patient] no but i can get one [doctor] okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good [patient] that sounds good to me [doctor] great okay david do you have any other questions [patient] no other questions at this time just i guess i just need to make sure to take my medication on time that's about it [doctor] yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well [patient] i will do my best [doctor] alright thanks hope you feel better [patient] thank you

ASSESSMENT AND PLAN

1. CHF.
 - Medical Reasoning: The patient’s recent epsiode resulting in the emergency room visit was likely caused by his dietary indiscretion and uncontrolled hypertension that we have been monitoring.
 - Patient Education and Counseling: I reviewed the echocardiogram results with the patient and discussed the importance of following dietary restrictions. I encouraged the patient to take his medication on a consistent basis. I advised him to purchase a scale to weigh himself daily.
 - Medical Treatment: He will continue Bumex 2 mg once daily. He was provided with a referral to a nutritionist in consultation for further assistance with his dietary requirements to lower his sodium intake.

 2. Hypertension.
 - Medical Reasoning: This is currently uncontrolled.
 - Patient Education and Counseling: I explained the importance of taking his medication on a daily basis. I encouraged the patient to purchase a blood pressure cuff and track his blood pressures.
 - Medical Treatment: He will continue Cozaar 100 mg daily as well as the Norvasc 5 mg once daily. I will order a renal artery ultrasound for further evaluation.

 3. Systolic ejection murmur.
 - Medical Reasoning. Stable.


[doctor] hi , stephanie . how are you ? [patient] i'm doing okay . how are you ? [doctor] i'm doing okay . um , so i know the nurse talked to you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] so , stephanie is a 49-year-old female with a past medical history significant for congestive heart failure , kidney stones and prior colonoscopy who presents today for an abnormal lab finding . so , stephanie , i called you in today because your hemoglobin is low . um , how have you been feeling ? [patient] over the past couple of months , i've been really tired and dizzy . lately , i've been really just worn out , even just , you know , walking a mile or going to work , doing things that i've done in the past every day that have been relatively okay , and i have n't gotten tired . and now , i've been getting tired . [doctor] okay , yeah . i , you know , the nurse told me that you had called with these complaints . and i know that we have ordered some labs on you before the visit . and it did , it c- you know , your , your , your hemoglobin is your red blood cell count . and now , and that came back as a little low on the results , okay ? so , have you noticed any blood in your stools ? [patient] uh , no , i have n't . i did about three years ago , um , and i did a colonoscopy for that , but nothing since then . [doctor] okay , yeah . i remember that , okay . and how about , you know , do your stools look dark or tarry or black or anything like that ? [patient] no , nothing like that . [doctor] okay . and have you been , um , having any heavy menstrual bleeding or anything like that ? [patient] no , not that i've noticed . [doctor] okay , all right . and any , have you passed out at all , or anything like that ? any weight loss ? [patient] no , no weight loss or passing out . i have felt a bit dizzy , but it has n't l- led to me passing out at all . [doctor] okay . so , you endorse some dizziness . you endorse some fatigue . have you , but you have n't had any weight loss , loss of appetite , anything like that ? [patient] no , nothing like that . [doctor] okay , all right . so , you know , let's talk a little bit about that colonoscopy . i know you had a colonoscopy about three years ago and that showed that you had some mild diverticuli- diverticulosis . um , no issues since then ? [patient] nope , no issues since then . [doctor] okay , all right . and then i know that , uh , you know , you have this slightly reduced heart function , you know , your congestive heart failure . how have you been doing watching your salt intake ? i know that that's kind of been a struggle for you . [patient] um , it's been more of a struggle recently . i've been traveling a lot . i went up to vermont , um , to go , um , explore the mountains . and along the way i stopped at , you know , mcdonald's and got two cheeseburgers . and so , i , i could be doing better . i've noticed some swelling in my , my legs . um , but nothing too extreme that where i thought i should call . [doctor] okay , all right . and any shortness of breath or problems lying flat at night , anything like that ? [patient] no , nothing like that . [doctor] okay , all right . and then in terms of the kidney stones , i know that you had those a couple years ago , as well . any recent flare ups ? have you had any , any back pain , flank pain , anything like that ? [patient] no , nothing like that . [doctor] okay . any blood in your urine that you've seen ? [patient] no . [doctor] okay , all right . um , okay . well , i know that the nurse did a review of system sheet when you came in . and we've just talked a lot about your , your s- your symptoms , you know , your dizziness , your fatigue and that type of thing . anything else that i might have missed , fever chills , any nasal congestion , sore throat , cough ? [patient] uh , i've had a little bit of nasal congestion just because with the seasons changing , i , i get seasonal allergies . but everything else has been okay . [doctor] okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] hey , dragon , show me the vital signs . so , here in the office today , your vital signs look great . your blood pressure is fine . your heart rates r- right where it should be , which is good , okay ? i'm just gon na do a quick exam . and i'll let you know what , what i find , okay ? [patient] okay . [doctor] all right . so , your physical , physical examination looks fine . so , on your heart exam , i do hear a three out of six systolic ejection murmur , which we've heard in the past , okay ? and on your lower extremities , i do notice some trace to one plus pitting edema in your ankles , which is probably from the salt intake , okay ? [patient] mm-hmm . [doctor] so , we'll talk about that . i wan na just look at some of your results , okay ? [patient] okay . [doctor] hey , dragon , show me the echocardiogram . so , i just wanted to go over the results of your last echocardiogram , that was about six months ago . that shows that you do have the low pumping function of , of your heart at about 45 % , which is not terrible . and it does show that you have some moderate mitral regurgitation . so , that's that slight heart murmur i heard in your exam , okay ? hey , dragon , show me the hemoglobin . and here , this is the hemoglobin that i was referring to . it's low at 8.2 , okay ? so , we'll have to talk a little bit about that , all right ? [doctor] so , let me go over a little bit about my assessment and my plan for you , okay ? so , for you first problem this new anemia , uh , i wan na go ahead and send off some more labs and anemia profile , just to see exactly what type of anemia we're dealing with . i also wan na go and refer you back to the gastroenterologist for another evaluation , okay ? hey , dragon , order referral to gastroenterology . so , they're gon na do , uh , probably do an endoscopy and another colonoscopy on you . um , but again , i wan na send off those labs just to make sure that it's not something else , okay ? [patient] okay . [doctor] for your next problem your congestive heart failure , um , i do think you're retaining a little bit of fluid . so , i'm gon na go ahead and start you on some lasix 40 milligrams once a day . i want you to continue you on your toprol 50 milligrams daily . and as well your , as well , as your lisinopril 10 milligrams a day . i really want you to watch your salt intake , okay ? get a scale , weigh yourself every day . and call me if your weight starts to go up , okay ? [patient] okay . [doctor] 'cause i might need to give you more diuretic . [patient] all right . [doctor] and for your last problem your kidney stones , uh , i think everything seems to be fine right at this time . again , continue to watch your diet and stay hydrated . um , and i know that might be a little difficult with the diuretic , but do your best . uh , and give me a call if you have any question , okay ? [patient] okay . [doctor] all right . any questions right now ? [patient] not that i can think of . [doctor] okay , great . hey , dragon , finalize the note .

ASSESSMENT AND PLAN

Ms. Stephanie Diaz is a 49-year-old female with a past medical history significant for congestive heart failure, kidney stones, and prior colonoscopy, who presents today for abnormal labs.

 Anemia.
 • Medical Reasoning: This is a new issue. Her recent hemoglobin level was low at 8.2, but she denies any signs of gastrointestinal bleeding or urinary tract bleeding, as well as any abnormal menstrual bleeding. Her colonoscopy from 3 years ago demonstrated mild diverticulosis.
 • Additional Testing: We will order an anemia profile for further evaluation.
 • Specialist Referrals: We will refer her back to gastroenterology for repeat evaluation with possible endoscopy and colonoscopy.

 Congestive heart failure.
 • Medical Reasoning: She has noticed some lower extremity edema. Her echocardiogram from 6 months ago demonstrated a reduced ejection fraction of 45%, as well as moderate mitral regurgitation.
 • Medical Treatment: We will initiate Lasix 40 mg once daily, and continue with Toprol 50 mg daily and lisinopril 10 mg daily.
 • Patient Education and Counseling: She should continue to limit her sodium intake. I advised her to monitor her daily weights and notify me if these start to increase.

 Kidney stones.
 • Medical Reasoning: She as asymptomatic denies any recent flare ups.
 • Patient Education and Counseling: I encouraged her to continue with dietary modifications and proper hydration. She will contact me with any questions or concerns.


[doctor] hello larry how are you doing today [patient] i've been better my primary care doctor wanted me to see you for this back pain that i've been having for a couple of years now [doctor] okay [patient] and i have tried so many things and just nothing seems to work [doctor] i'm sorry to hear that now do you remember what caused the pain initially [patient] you know i never fell or was in an accident but i do remember it all happened like i started having back pain after i was moving furniture one weekend [doctor] okay and now can you describe the pain for me [patient] yeah it feels like a sharp stabbing pain in my back and it does go down even down to my right leg sometimes all the way down to my toe it feels like my big toe [doctor] okay [patient] and i also feel like i just ca n't get comfortable which is worse when i sit down okay yeah [doctor] okay now with that do you have any numbness or tingling associated with your back pain [patient] yeah i do get some numbness and tingling especially to my right leg that goes down to my foot [doctor] okay [patient] let me separate these [doctor] and how about a loss of sensation in the genital or the rectal area [patient] no nothing like that [doctor] okay now do you have any weakness [patient] i would n't say i have any weakness no [doctor] okay do you experience like any loss of control of your bladder or your bowels [patient] no [doctor] okay now you mentioned earlier that you you have some tried tried some things in the past so tell me what were they [patient] so i've tried some physical therapy before and so when it gets really bad they've even had to prescribe some strong pain medications for me but that was only temporary and they even mentioned surgery to me in the past but i really would like to avoid surgery [doctor] okay sure so tell me what is your day like [patient] my day so i try to be as active as i can but of course it's been difficult with my back pain and so because of that i have gained some weight over the past years [doctor] okay alright well i'm sorry to hear that i know that you used to like playing golf [patient] yeah i and you know golf is relatively new for me i've been trying to get into it but this has definitely set me back [doctor] yeah i'm sorry yep probably now at the peak of you know just learning it and being able to do more with it this comes and this happens right [patient] exactly [doctor] well let's see what we can do for you here so you can go out into the you know the golf course again now do you tell me do you have any family members with spine conditions [patient] no i ca n't recall any family members [doctor] okay alright and do you smoke [patient] not now i i quit about twenty years ago [doctor] okay alright well alright well i like to do a quick physical exam on you here [patient] okay [doctor] i'm gon na go ahead here i reviewed your vitals and they overall look pretty good so that's a good sign now on your musculoskeletal back exam there is no overlying erythema and that just means redness or ecchymosis and that just means bruising of the skin now there is midline tenderness at l4 l5 disk space with right-sided lumbar paravertebral tenderness so do me a favor and i'm gon na just have you you know bend forward and straighten up a bit [patient] okay that's painful [doctor] sorry so definitely some pain with lumbar flexion and supine straight leg test is positive so on your neurological examination there is decreased sensation to light touch at the right lateral thigh at l4 dermatome okay and i'm just gon na take a look at your knees here real quick and then your your ankles so patellar and achilles reflexes are symmetrical so good now i reviewed the results of your mri and it shows disk herniation with nerve impingement so let me tell you about my assessment and plan here larry so for your problem of chronic lumbar back pain so based on your symptoms your exam and reviewing your mri results your symptoms are consistent with an l4 l5 herniated disk with radicul radiculopathy so this means that one of your disks that sits between your spinal vertebrae is bulging out and this bulge is pinching on some nerves and that's why you feel that tingling in your leg so yeah yeah so i am recommending a spinal injection with a strong inflammatory medication called a corticosteroid and what i do is i will inject the corticosteroid into that lumbar spine under fluoroscopy which you can think of you know an x-ray to help localize to the exact area of your pain now this should this should help the inflammation that is causing the pain so what do you think about that [patient] is there something i'm gon na have to do all the time [doctor] well you know patients are different so what we do is we will monitor you and we see how you respond to the injection and the patient's intervals can be different as well but we usually do not do more than four times a year [patient] okay okay [doctor] alright and it's not a long procedure it's it's relatively quick and common and you should be out of the office within an hour [patient] okay [doctor] okay [patient] alright sounds good [doctor] alright well let's go ahead and get you started on the first one today if that works for you if not we'll get you scheduled to start your first injection [patient] alright thank you [doctor] alright thank you [patient] bye

ASSESSMENT

L4-5 herniated disc with radiculopathy.

PLAN

After reviewing the patient's examination and MRI findings today, I have discussed with the patient that his symptoms are consistent with an L4-5 herniated disc with radiculopathy. I have recommended that we treat the patient conservatively with a corticosteroid injection under fluoroscopy. With the patient's consent, we will proceed with a cortisone injection into the lumbar spine today."


[doctor] hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee [patient] yes i hurt my knee when i was skiing two weeks ago [doctor] okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury [patient] so i was flying down this black diamond you know like i like to do [doctor] yes [patient] and this kid who was going faster than me spent by me so then i tried to speed past them and then i ran into a tree and twisted my knee [doctor] so we were downhill skiing racing at this point okay is it your left or your right knee [patient] it's my right [doctor] okay and does it hurt on the inside or the outside [patient] the inside [doctor] okay so the medial aspect of the right knee when you fell did you hear a pop [patient] i did yes [doctor] okay alright [patient] i think that was my left knee [doctor] okay okay alright so we got we got ta pick one if it if it [patient] i'm just trying to be real [doctor] no [patient] what happens in the in a real [doctor] a hundred percent so how about this right now you're like i what i'm hearing is that you're experiencing bilateral knee pain like both of your knees hurt but i'm assuming that like your right knee hurts more is that correct [patient] yeah my left knee does n't really hurt [doctor] uh uh [patient] that's the one that popped it the left knee just feels unstable but my right knee hurts [doctor] gotcha gotcha okay yeah i think hmmm alright so we're gon na we're gon na go ahead and look at this sort of but on a scale of one to ten how severe is your pain [patient] it's a seven [doctor] okay that's pretty bad alright and does it has it been increasing or like rapidly or slowly over the last few days [patient] it's been slow [doctor] okay alright [patient] but sometimes it gets to an eleven [doctor] okay what would do you know if you are doing something that would cause it to be an eleven are you back on your ski's [patient] no i ca n't ski [doctor] okay [patient] usually when i walk my dog [doctor] okay does it hurt more when you walk for longer periods of time [patient] yes [doctor] okay how long does the pain last [patient] for as long as my walk is and i do n't sometimes i walk five minutes kinda depends on the wind [doctor] okay alright [patient] sometimes i walk there is [doctor] okay alright have you done anything to help with the pain [patient] well i wear a brace and i have used a lot of thc cream on it [doctor] okay alright thc cream is an interesting choice but do you think that's been helpful [patient] yes [doctor] alright have you taken [patient] reasons [doctor] not a problem have you taken any medications [patient] no just gummies [doctor] okay like vitamins or more thc [patient] kind of like thc gummies [doctor] thc gummies [patient] my grandma gave them to me [doctor] thc gummies from grandma that's an excellent grandmother that you have okay have you noticed any swelling stiffness tenderness [patient] yeah i i get a lot of swelling and it really is it's very stiff in the morning until i get walking [doctor] okay alright and then have you had any hospitalizations or surgeries in the past [patient] well i had surgery on my right knee before [doctor] okay so you've had surgery before alright do you remember what kind of surgery [patient] i do n't know they told me they reconstructed the whole thing i was fourteen i was a really good gymnast back then really good [doctor] okay [patient] and i was doing a back summer salt and i felt a pop then and then since that time i've really had problems with my knee [doctor] uh uh [patient] but you know the athlete that i am i can still really ski very well so i just kept going [doctor] okay [patient] and i'm really tough my pain tolerance is very high [doctor] okay okay okay how so do you have any other exercises that i might wan na know about outside of intense gym and ski events [patient] no i think that's about it [doctor] okay and how frequently do you normally ski [patient] i ski probably three times a week [doctor] okay and then are you on any medications at this time other than the thc [patient] no [doctor] okay alright what [patient] nothing no [doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and start my examination i'm just gon na call it out for the sake of being able to document it appropriately and you or just just let me know if you want me to explain anything further so with your knee i know that you said it hurts on the right inside a lot right so when i press on the inside of your knee does that hurt [patient] yes [doctor] okay and when i press on the outside of your left of your right knee sorry does that hurt [patient] no [doctor] okay alright so when i move your your kneecap does that hurt [patient] no it kinda makes a shooting pain down to my ankle though [doctor] okay [patient] but it does n't hurt my knee [doctor] okay so does the pain radiate frequently [patient] no [doctor] okay [patient] i've never really noticed it just messed with my kneecap [doctor] okay alright on your skin exam i do appreciate some mild swelling and bruising that's really interesting since it's been two weeks with your knee are you able to bend it [patient] yes [doctor] okay and then when you walked in on your gait i think i think i did appreciate a slight limp are you i i i i think you are you are protecting one of your knees does that sound familiar [patient] yeah i waddle pretty pretty good now [doctor] okay alright and when you move your knee away from your body you're bending like your you're pulling it towards me does that hurt [patient] yes [doctor] okay and then when you pull your knee back towards you does that hurt [patient] no [doctor] alright so pain on dorsiflexion but not on plantar flexion plantar flexion okay alright so what we are gon na do right now i think i'm gon na look at your x-rays but when i when i look at the results of your x-ray i do not appreciate any fracture what i am noticing is the development of a little bit of arthritis and that could explain like why you say that your joints hurt a bit more during like windy weather and what not so this is what we're gon na do for my assessment and plan right the first thing is i think you have a strain of your posterior cruciate ligament what that means is what that will mean for you though is that we are gon na continue to brace your right knee that's gon na hopefully take off some of the stress that you might be putting on it especially since you're limping i am going to recommend you for physical therapy i think it would be an i think it's a good idea to maybe start three times a week to get your strength back into your knee i would recommend not skiing or doing any gymnastics for now and i think that physical therapy will really help considering the injury that you had when you were fourteen i'm gon na prescribe you some medications i do n't necessarily recommend consuming gummies at the same time but the medications i'm gon na give you are gon na be meloxicam fifteen milligrams you're gon na take that once a day that will help with like the swelling and the bruising i'm also gon na prescribe you just like a higher strength nsaid so ibuprofen eight hundred milligrams a day you can take that twice a day as needed for your left knee i think you are i think you just kind of like strength a little bit but like not enough to necessarily require any kind of like medication or bracing i think you just take it easy on your body i know that you're like very active from what i hear and i i think that that's really exciting but i think you might need to listen to your body and give yourself a bit of a break you'll be able to do like several workouts when you go to when you go to physical therapy but you know let the yeah let your therapist be your guide about like what you should and should not be putting your body through does that make sense [patient] yes [doctor] alright do you have any questions right now [patient] no thank you so much [doctor] no problem

ASSESSMENT

1. Right knee posterior cruciate ligament strain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have explained to her that her x-rays did not reveal any signs of a fracture. I have recommended that we treat the patient conservatively with continued bracing. We will initiate formal physical therapy 3 times per week to strengthen her right knee. Additionally, I have prescribed the patient meloxicam 15 mg and ibuprofen 800 mg twice daily as needed. She should discontinue the use of her THC gummies while taking these medications.

 Regarding her left knee, I do not believe she will need any further medications to treat this. I have advised her to avoid skiing or gymnastics at this time.
 "


[patient] hi good afternoon joseph how are you doing today [doctor] i'm doing well but my my big toe hurts and it's a little red too but it really hurts okay how long has this been going on i would say you know off and on for about two weeks but last week is is when it really became painful i was at a a trade show convention and i could n't walk the halls i could n't do anything i just had to stand there and it really hurt the whole time i was there [patient] okay does it throb ache burn what kind of pain do you get with it [doctor] it's almost like a throbbing pain but occasionally it becomes almost like a a sharp stabbing pain especially if i move it or spend too much time walking i i find myself walking on my heel just to keep that toe from bending [patient] okay sorry i got a text and [doctor] well that's okay you know what i i you know i what i really you know i love to ride bikes have you you ride bike at all [patient] no i hate riding a bike i'm more of a runner [doctor] my gosh i love to ride i ride the lot of rails the trails i mean i go all the last year i put in over eight hundred miles on rails the trails [patient] yeah those those are nice [doctor] yeah [patient] does it does riding your bike bother your big toe [doctor] no because i i kinda pedal with the the back of my feet you know on that side [patient] okay do do you wear clips or are you just wearing a regular shoe and on a regular pedal [doctor] i'm on a regular shoe some most of the time i'm in my flip flops [patient] okay okay the how is there anything that you were doing out of the ordinary when this started [doctor] no i do n't that's the thing i do n't remember an injury if it was something that i injured i think i would have just ignored it and would n't have showed up here but when it got red and warm to touch that's when i i was really concerned [patient] okay do does even light pressure to it bother it like at night when you're laying in bed do the sheets bother [doctor] absolutely i was just gon na say when i'm in bed at night and those sheets come down on it or i roll over yeah that hurts a lot [patient] okay have you done anything to try to get it to feel better any soaks or taking any medicine [doctor] i take you know like a two ibuprofen a day and that does n't seem to help [patient] okay [doctor] alrighty [patient] let me see your your foot here and let me take your big toe through a range of motion if i push your top to bottom [doctor] yeah ouch [patient] big toe joint that okay and let me move it up where as i bend it up does that hurt [doctor] it hurts but not as much as when you moved it down [patient] okay so i'm moving it down here and it i've got about ten degrees of plantar flexion does that hurt [doctor] yeah it a little when you take it a little further [patient] if i go a little bit further to twenty degrees does that hurt [doctor] that hurts more yeah [patient] okay if i push in on your big toe and move it back and forth does that hurt [doctor] yes it does and it it's almost like those joints that when you push it back it's almost like it's grinding a little bit too [patient] okay if i push in between your big toe and your second toe here does that hurt [doctor] a little bit but not terrible [patient] okay what about if i push on the other side here [doctor] yeah yeah right there on the outside of it absolutely [patient] okay [doctor] yep [patient] okay and i'm feeling a little bit of bone spur here as well let me let me get an x-ray [doctor] okay [patient] and after we take a peek at that we'll develop a plan [doctor] okay [patient] so at this point what would i do if i'm going out of the room and then coming back [doctor] you could hit pause or hit the stop button and just restart it the next time you come in [patient] okay alrighty so taking a look at your x-ray and you do have you you have a large spur there on the top of your big toe joint [doctor] oh [patient] and you've lost a lot of the cartilage [doctor] oh [patient] and so you you've got some arthritis in there we we call this hallux rigidus and treatment for this to start off with we we put an insert in your shoe called an orthotic and we give you a little bit of anti-inflammatory medication or like a drug called meloxicam you only have to take it once a day [doctor] okay [patient] it's usually pretty well tolerated have you ever had any trouble with your stomach [doctor] no never never had any problems with my stomach i love the i love the mexican's food the hotter the better so i hope i never get a problem with my stomach [patient] i hope you do n't either one of the things that we get concerned about with an anti-inflammatory like that is that it can irritate the stomach so if you do start to notice that you're getting heartburn or pain right there [doctor] yeah [patient] below your your sternum you would need to stop taking the medicine and give me a call [doctor] okay [patient] okay [doctor] okay [patient] and i wan na see you back in two weeks to see how you're doing with that if you're not seeing significant improvement then we may have to talk about doing things that are a little more invasive like doing a shot [doctor] okay [patient] or even surgery to clean out the joint sometimes [doctor] is that surgery [patient] i have to [doctor] would that be [patient] i'm sorry [doctor] would that be surgery clean out the joint [patient] yeah that would [doctor] okay [patient] that would be surgery if if we went in and cleaned out the joint sometimes in really severe cases we even just have to fuse the big toe joint we put it in a position of optimal function and we fuse it there and then your pain goes away you lose some motion but you've already lost quite a bit of motion and and the pain goes away so that that surgery really is very effective but let's try to run from my knife a little bit longer [doctor] okay well you know i do n't think i'm gon na be able to do my work job i'm on my feet every day and i it's and and quite frankly it's fishing season so do you think you can give me a couple weeks off so i can get out and get some fishing done [patient] no i want you to be doing your regular activities i want to know how this because if i put you out of work can you come back in and say it feels better well is was it because of the treatment or because of the rest so no i want you to keep working i want you to do your regular activities and i really want you to put these orthotics to the test and this medicine to the test and we will see how you're doing in two weeks [doctor] okay where i really like catching blue going croppy so okay we'll we'll i'll i'll keep working then i'll find time to do that later [patient] very good we will see you in two weeks [doctor] okay thank you

ASSESSMENT

Right foot hallux rigidus.

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 revealed hallux rigidus. We discussed treatment options for this and I have recommended that we begin with conservative treatment in the form of custom orthotics. I have also prescribed the patient meloxicam once a day to treat the pain. The patient was instructed to discontinue use and contact the office if gastrointestinal issues develop. I advised the patient that I want him to continue his regular activities.


[doctor] hi jacqueline how are you doing today [patient] i'm doing okay i'm just really anxious about my recent blood work that my pcp did and said that i have hepatitis c i'm just really surprised because i've been feeling fine [doctor] okay so were you ever told in the past that you have hepatitis c [patient] no never [doctor] okay and do do you have any history like iv drug use known that you know or do you have any known to have any like hepatitis c positive partners [patient] i mean like years ago i used to party a lot and even use iv drugs but i've been clean for over fifteen years now [doctor] okay well very good you know congratulations on that that's that's a great great achievement so tell me though how about alcohol use [patient] i used to drink a lot a lot more alcohol now i probably would say i drink about a beer a day [doctor] okay [patient] and maybe slightly more on the weekends but nothing like how i used to [doctor] okay alright how about smoking have you ever smoked [patient] i do smoke i'm down to one to two cigarettes a day it's just really been tough to just get rid of those two but i've cut down a lot i used to i was up to one point or a pack and a half a day [doctor] wow okay alright so yeah you you definitely have decreased that so that's again good for you on that one so hopefully you keep you keep that up [patient] thing [doctor] so tell me do you have any other medication conditions [patient] do i do i no otherwise i'm i'm feel pretty good i had my physical there was nothing else the the only thing i was telling my pcp is i do feel like tend to be really tired at the end of the day after working but otherwise i've been good [doctor] okay and and has work been not hard lately you've been busy it sounds like [patient] i know i have been busy but not really much more than usual [doctor] okay [patient] so that's why i was kind of marking because i mean i used to you know be able and be fine but i just lately have been feeling like i'm getting enough sleep but i still get very tired at the end of the day [doctor] okay alright well i hope you're not working too much and then you'll able to at least find some time with the family [patient] yeah i'm i yeah i tend to be a workaholic but yes i i am working on that [doctor] okay well i hope kids are doing okay [patient] they are thank you [doctor] okay good so tell me what conditions what kind of conditions run in your family like is there do you have hypertension diabetes or [patient] yeah all of all of the above [doctor] okay [patient] hypertension diabetes and also depression [doctor] okay and depression okay alright well let's go ahead and do a quick physical exam on you here i reviewed your vitals and everything there looks good so that's good and now on general appearance you appear in no distress and no jaundice on skin exam let me go ahead and listen to your heart here great on your heart exam you have a nice regular rate and rhythm with a two out of six six systolic murmur appreciate appreciated that's that has n't changed from last year so we will just continue to monitor that monitor that as well okay [patient] okay [doctor] alright now let me listen to your lungs here very good so your your lungs are clear with no wheezes rales or rhonchi and let me go ahead and listen to your abdomen great your bowel sounds are present your abdomen is soft with no hepatospleno splenomegaly ca n't talk to appreciated so let me now check your musculoskeletal exam here great i i did n't see any gait disturbance and no edema so that's great so jacqueline i did review the results of your recent blood blood work and your hcv antibody test was positive and your liver panel that was done showing an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so what that all means and let me go ahead and tell you about my assessment and plan here for your first problem of hepatitis c your initial labs are consistent with hepatitis c so based on the the once i just discussed with you there now hepatitis c is a viral infection that affects the liver so you most likely may have had it for years now so the next step that i would like to do is to confirm the diagnosis with some additional blood work that includes checking the hep c rna and also the hcv genotype okay now i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and i'm gon na do this by ordering a special ultrasound and with this information i'm gon na be able to know how to proceed as far as treatment [patient] okay [doctor] alright now i know that was a lot of information do you have any questions for me [patient] yeah so should i be worried about my wife and my kids should they be tested as well [doctor] yes so we can start with the same screening that you have had for you for all of them first okay [patient] okay alright so i'll make sure i'll have them set up an appointment with our our family doctor [doctor] okay great so if you do n't have any other questions i'm gon na have the nurse check you out and get all that scheduled and i'm gon na see you in about three weeks [patient] alright perfect [doctor] alright [patient] thank you [doctor] take care jacqueline [patient] okay bye [doctor] bye

ASSESSMENT AND PLAN

1. Hepatitis C.
 - Medical Reasoning: Her recent blood work revealed a positive HCV antibody. She does have a history of intravenous drug use, but she has not used drugs in over 15 years.
 - Patient Education and Counseling: We discussed the nature of hepatitis C in detail. I advised the patient to have her spouse and children tested for hepatitis C as well.
 - Medical Treatment: I'm going to order additional labs including a hepatitis C RNA and HCV genotype to confirm the diagnosis, as well as a Fibroscan to assess the severity of the condition.


[doctor] i know the nurse told you about dax . [patient] mm-hmm [doctor] i'd like to tell dax a little bit about you , okay ? [patient] sure . [doctor] so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ? [patient] um , relatively speaking , okay . it was kind of a , a tough spring with all the pollen and everything and , uh , we dropped my oldest daughter off at college and moved her into her dorm , so little stressful , little chaotic , in the heat of the summer , but so far , so good . [doctor] okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing . [patient] yeah . [doctor] so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year . [patient] yeah , i've been staying on top of the meds , and i have n't had any incidents in a while , so it's , it's been pretty good , and everything's managed and maintained . um , still kind of working with my hypertension . that's been a little bit more of a struggle than anything . [doctor] okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ... [patient] i ... i'm pretty regular with the medications during the business week , but on there's weekends , you know , if i'm on the fly or doing something , sometimes i forget , or i forget to bring it with me . uh , but for the most part , it's been okay . [doctor] okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ? [patient] other than during the heat and the pollen , it's been pretty good . [doctor] okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ? [patient] sometimes i , i regularly , uh , go for a run in the morning . that's my workout , and sometimes if it's , uh , relatively humid , i'll struggle a little bit , and i might feel a little bit of pounding in my chest . it usually goes away , but , uh , again , for the most part , it's been pretty good . [doctor] okay , so you also have some shortness of breath with with exertion . [patient] correct . correct . [doctor] all right , and how far are you running ? [patient] uh , like 4 to 5 miles a day . [doctor] okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure . [patient] mm-hmm . [doctor] hey , dragon , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , dragon , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it has in the past , so continue on the current medication . [patient] mm-hmm . [doctor] all right , so i'm just gon na listen to your heart and lungs and check you out , okay ? [patient] you got it . [doctor] okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today . [patient] mm-hmm . [doctor] and in reviewing the results , it looks like your ekg is completely normal , so that's good . [patient] good . [doctor] so i'm not too concerned about that , that chest pounding . hey , dragon , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my assessment and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well- [patient] mm-hmm . [doctor] . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ? [patient] uh , actually , i do need a refill . [doctor] okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow up with the surgeon anymore . and then for your last problem , your hypertension . [patient] mm-hmm . [doctor] you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , dragon , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ? [patient] perfect . [doctor] all right . good to see you . [patient] same here . [doctor] hey , dragon , finalize the note . the nurse will be in . [patient] thank you .

ASSESSMENT AND PLAN

Ralph Barnes is a 62-year-old male who presents for his annual examination.

 Annual visit.
 • Additional Testing: I have ordered his routine blood work and will follow up with the patient via the portal once results are back.

 Depression.
 • Medical Reasoning: He is doing well with his current regimen.
 • Medical Treatment: He can continue Prozac 20 mg a day and I provided a refill of that today.

 History of lobectomy.
 • Medical Reasoning: I do not think we need to do any more work up for this issue. He is able to exercise a lot and his breathing function is back. I do not think he needs to follow up with the surgeon anymore.

 Hypertension.
 • Medical Reasoning: He is doing well on his current regimen. His blood pressure was normal today and has been trending well over the past several years.
 • Additional Testing: I ordered an echocardiogram to evaluate his murmur.
 • Medical Treatment: He can continue Norvasc.


[doctor] eugene walker , n- date of birth 4/14/1960 . he's a 61-year-old male who presents today , uh , for a routine follow-up with chronic medical conditions . [doctor] of note , the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 1/22/2013 . regarding his blood work from 4/10/2021 , the patient's alkaline phosphatate- phosphatase , excuse me , was elevated to 156 . his lipid panel showed elevated total cholesterol of 247 , hdl of 66 , ldl of 166 , and triglycerides at 74 . the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . [doctor] good morning , mr. walker . how are you doing ? i mean , it's been a crazy year . [patient] i'm doing fine , for the most part , but there are a few things i want to cover today . [doctor] sure . go right ahead . [patient] uh , well , i'm having more fatigue , but i do n't know if it's age or if it's just , you know , drained at the end of the day . but i still ride my bike . i ca n't go as fast as i used to . i'm still riding , and , you know , after a long bike ride , i'll sit down and then boom . i'm out , you know ? [doctor] yeah . what's a long bike ride to you ? [patient] uh , 20 to 30 miles . [doctor] 20 to 30 miles on a road bike ? [patient] yeah , road bike . i think it's a time thing . if i had more time , i would try to do my 40 miles , but i have n't done that . obviously , we're too early in the season so my typical ride is , like , 20 , 30 . in years back , i could do 40 on a good day . i can still do 20 but , you know , i'm tired and have to take a break when i get home . [doctor] yeah , i understand . [patient] and tyler's my buddy . he's always nice and waits for me , but i used to be able to beat him . but now , he waits for me all the time . he's older than me and it- it kills me . [doctor] yeah , i can imagine that would upset me too . [patient] well , the last time , you know , you found a heart thing , then . just making sure that the valve is holding out , you know ? [doctor] right . so , when was your last stress test ? [patient] it was september 9th , 2019 , because i'm eight years out from surgery , and back then , they said , you know , it's going to last eight years . and i'm at that year , so i just want to make sure . i asked dr. lewis for an echocardiogram to see how i'm doing . [doctor] yeah . [patient] but it's not ... like , nothing has changed drastically since i saw you . [doctor] okay , good . do you still go down to hopkins at all ? [patient] no , not at all . i just get follow-ups intermittently , here . going there is just ... it's too much stress . [doctor] okay . [patient] one more thing , i want to make sure i do n't forget . my wife and friends tell me that when i walk , i purse my lips when i'm breathing . other doctors have said ,  did you notice your pursed lips breathing ?  i do n't know if that's a bad habit or what . [doctor] okay . is there any wheezing associated with that ? [patient] no , no wheezing . [doctor] and you're able to bike 30 miles and mostly keep up with your friend , tyler , correct ? [patient] yeah . the only other thing i want to mention is it's not like i do routine testicular exams , but i know i have this little nodule on my right testicle . [doctor] on the testicle or the epididymis ? [patient] epididymis . uh , i really do n't know . i'm not super concerned . i read a little online . just wanted to ask you . [doctor] and did you have a vasectomy ? [patient] no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those were the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know ? i just know you would ask those questions . [doctor] what time are you going to sleep , and about how many hours do you sleep a night ? [patient] um , it varies . usually , i get six to seven hours of sleep . i get out of bed some days to be at work by 7:00 , lecture , and i try to work out in the morning . i- i do n't ... i'm not ... i'm not always successful , and now what i do is i- i do make reservations twice a week for a 5:45 swim in the morning . [doctor] okay , so you're getting six to seven hours of sleep , and has your wife ever mentioned if you snore or stop breathing at any time ? [patient] i believe i snore a little bit , but she's never said anything about me not breathing . [doctor] okay . so , you're currently taking vitamin d3 , around 5000 units on sundays , and two thous ... or 50,000 units on sundays , excuse me , and 2000s on the other six days , and then clindamycin prior to dental procedures , correct ? [patient] yeah , that's right . [doctor] have you had a covid-19 shot yet ? [patient] i've received both . my first dose on january 15th , '21 and my second on february 5th , '21 . [doctor] good . if you'd hop up here on the table , we're just going to do a physical exam . [doctor] well , mr. walker , overall you're doing well . i'm going to order an echocardiogram and a stress test . i also recommend that you follow up with cardiology , i think dr. vincent sanchez would be a great fit for you . [patient] all right . [doctor] also your recent labs showed an elevated alkaline phosphatase level at 156 . now this could be related to your liver but most likely related to your bone health . we're going to check a few labs today . [patient] you're going to have them done today ? [doctor] yes , sir , and we will send the results through your patient portal unless something is way off then we'll give you a call . [patient] sounds good . [doctor] now as far as your breathing , i observed the pursed lip breathing and your exhalation is low . i think you should do a pulmonary function test to further evaluate , and i'll order that as well . [doctor] now the nodule in your right testicle should be evaluated by urology , and we will place that referral today , also . [patient] sounds like i'm going to be busy getting this all checked out . [doctor] yes , sir . now you are due for your mmr and i'm recommend you get the shingles vaccine as well . you have completed your covid-19 , so that's good . [doctor] now i'm going to have , uh ... have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies . [doctor] do you have any other questions for me ? [patient] no , doc . i think you covered it all . [doctor] great . okay , the nurse will , uh , be back in a minute to give you mmr today , and the front desk will line up a time to do the shingles vaccine next month . [patient] thanks , doc . have a great day . [doctor] all right , i used my general physical exam template for respiratory notate : pursed lip breathing , low exhalation phase , clear to oscillation , no wheezing . uh , genitalia notate : right testicle with two to three millimeters palpable nodule does not feel as if it will ... does not feel as if with the epididymis or variococele ; left testicle , normal ; no hernia . all other portions of the physical exam are normal default . [doctor] assessment history of the aortic aneurysm repair : the patient underwent and aortic valve replacement and ascending aortic aneurysm repair on 1/20/2013 . he is doing well overall and currently asymptomatic . he is currently not seen by cardiology routinely . suggest the following up and suggested vincent sanchez as his physician . we will perform an echocardiogram , eh , slash , stress test . [doctor] elevated alkaline phosphatase level . most recent cmd showed elevation at 156 . this could be related to his liver but most likely re- related to his bone health . i've ordered an alkaline phosphatase and again a gt . [doctor] lung field abnormal finding on exona ... excuse me , on examination . the patient has been noted to purse his lips while breathing . he was found himself ... he has found himself feeling more fatigued at the end of the day . he does bicycle around 20 to 30 miles at a time . his exhal- exhalation phase is low on exam , and i've ordered pfts today to further ... for further evaluation . [doctor] the right testicular nodule is about two to three millimeters , i've noted on the exam . there's no hernia palpable , and i have suggested reaching out to ro ... urology for a possible ultrasound . [doctor] preventative health : the most recent blood work was reviewed with no significant abnormalaries ... abnormalities other than the cmv . uh , we will perform mmr titer today . i have suggested the shingles vaccine and he is fully vaccinated against covid-19 . [doctor] patient will return , uh , for a follow-up in one year for a wellness visit , sooner if needed . he is to call with any questions or concerns .

ASSESSMENT

• History of aortic aneurysm repair.
 • Elevated alkaline phosphate level.
 • Lung field abnormal finding on examination.
 • Right testicular nodule.
 • Preventative health.

PLAN

Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions.

 History of aortic aneurysm repair.
 - Overall, he is doing well and currently asymptomatic.
 - Currently he is not seen by cardiology routinely and I have suggested he follow up with Dr. Tyler Sanchez.
 - Ordered echocardiogram and stress test.

 Elevated alkaline phosphate level.
 - Most recent CMP showed elevation at 156 IU/L.
 - This could be related to his liver but most likely related to his bone health.
 - Ordered an alkaline phosphatase and gamma GT.

 Lung field abnormal finding on examination.
 - The patient has been noted to purse his lips while breathing.
 - He had found himself feeling more fatigued at the end of the day.
 - He does cycle 20 to 30 miles at a time.
 - His exhalation phase was low on exam.
 - Ordered pulmonary function testing for further evaluation.

 Right testicular nodule.
 - 2 to 3 mm nodule noted on exam. There is no palpable hernia.
 - Referral placed to urology for possible ultrasound.

 Preventative health.
 - Most recent blood work reviewed with no significant abnormalities.
 - He is fully vaccinated against COVID-19.
 - Recommend shingles vaccine next month.
 - MMR titer performed today.


[doctor] alright [patient] you're ready just [doctor] ready [patient] hi kyle how are you today [doctor] i'm doing well i'm just anxious about my pcp told me that i had some abnormal lab work and why she wanted me to be seen by you today [patient] yeah i bet that did make you nervous i i see that she referred you for a low immunoglobulin a level is that your understanding [doctor] yeah i mean i do n't even really understand what that means but yeah that's what she told me [patient] yeah that's a mouthful [doctor] yeah [patient] it it's the the one of the antibodies in your body and that that really makes that your body makes to fight infections it's a little bit low i'm happy to explain it a little bit more to you i just have a few more questions okay so let's start again here [doctor] i'll do this [patient] i i think i would break that [doctor] yeah i just saw that [patient] if you can do that [doctor] okay [patient] yeah so we'll we'll just [doctor] okay [patient] you can leave it the way it is for now i just i think break that up [doctor] okay alright so yeah that sounds fine for me [patient] yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections [doctor] yeah yeah i had a recent physical and she did this as part of her my physical i do tend to get infections but i do n't know i i'm so used to it so i do n't know if this is more than usual in the wintertime i get a lot of colds and they do seem to i always say that my colds kind of linger for a long time but i do n't know if it's more than usual [patient] okay how about any abdominal infections [doctor] diarrhea no [patient] frequently [doctor] no not that i can not that i say can think of [patient] okay what about your family are are anyone in your family that you know have immune deficiencies [doctor] no my family is actually pretty healthy [patient] okay and how about do you have any other medical conditions [doctor] yeah my pcp just started me on metformin i just got diagnosed with type two diabetes [patient] okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street [doctor] yes and that's probably part of the cause of my diabetes yes [patient] yeah well i guess you're gon na have to watch that [doctor] i know i know [patient] but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away [doctor] right [patient] but have you ever needed to receive a blood transfusion or blood products [doctor] no i actually tried to give blood but they i did n't qualify because i had recently traveled internationally [patient] okay where did you go [doctor] i was in zambia [patient] hmmm i heard that's beautiful [doctor] it's so beautiful it's so beautiful i had a great time [patient] okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial [doctor] no [patient] no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about the assessment and plan so for your first problem the that a iga deficiency is it very common immunodeficiency your your body makes many different types of antibodies in one of your z iga is just a little bit lower than normal now most of the time people live their entire life without even knowing they have that deficiency and function perfectly normal now some people may find that they get tend to get frequent respiratory tract or sinus or abdominal infections but this does n't necessarily seem to be the case for you now it can go along with other immunodeficiencies but i think there is a low likelihood hood in your case but we're gon na order some additional blood work that includes checking those other antibodies now do you have any questions on what i just told you [doctor] yeah so is there anything i need to do or should be watching for or should i be worried [patient] no i i really do n't think you need to be worried now we're gon na check these additional studies and that will give us some more guidance but really i think this is just a finding that's common to you and you know it it's many people have have have these type of you know immunodeficiency what i want you to watch for is those infections that do n't stop you have trouble getting it under control or you know any changes to your abdominal tract you know severe diarrhea [doctor] anything like that then you know we may want to look at it a little bit further but for now i do n't think there is anything significant we want to do now go ahead and get your lab work and [patient] bring you in for that now the only other thing that i would say is if you eat end up needing any blood products between now and when i see you next make sure you tell them that you have that iga deficiency [doctor] why is that [patient] well there is a risk that your body can strongly react to some blood products and they just need to know that so they're prepared so anytime you get blood just make sure you say that you have a history of a an an iga deficiency [doctor] okay okay thank you [patient] you're welcome [doctor] okay

ASSESSMENT

IgA deficiency.

PLAN

After reviewing the patient's examination today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that the results of his recent lab work is consistent with an IgA deficiency. I have recommended that we obtain additional blood work to check his other antibodies. I encouraged the patient to be aware of lingering infections or abdominal changes including diarrhea. If he experiences these issues, he should report them to my office so we may investigate further, however I do not believe there is a need for that at this time. In the meantime, he should report this IgA deficiency in the event that he needs any blood transfusions. Questions were invited and answered today."


[doctor] hi wayne how're you today [patient] i'm doing okay aside from this left shoulder pain that i've been having [doctor] okay and how long have you had this pain [patient] about i want to say a few weeks i think it's been about three weeks now [doctor] okay and do you remember what you were doing when the pain started [patient] honestly i've been trying to recall if i had any specific injury and i ca n't think of that [doctor] okay [patient] of anything the only thing i can think of is that i you know i am active and we've just been doing a lot of work in our basement so if i do n't know if i did something while doing that [doctor] okay alright tell me have you ever had pain in that shoulder before [patient] you know i i'm really active and so i i will get some aches and pains here and there but nothing that tylenol ca n't take care of [doctor] okay good but now are you able to move your arm [patient] you know i have trouble when i'm trying to reach for something or lift any objects and i do n't even try to reach it for anything over my head because then it'll really hurt [doctor] okay alright and and now are you having the pain all the time or does it come and go [patient] the pain is always there and then it gets worse like if i try to put any pressure on it it gets worse so if i'm laying at night if i try to even lay on that shoulder it's unbearable [doctor] okay and then tell me what have you taken for your pain [patient] i've been taking two extra strength tylenol every six to eight hours [doctor] alright and and did that help [patient] it does take the edge off but i still have some pain [doctor] okay well i'm sorry to hear that you know you know renovating the basement it can be quite a task and it can take a toll on you [patient] yeah i mean it's been fun but yeah i think it really did take a toll on me [doctor] yeah what what are you doing with your basement are you are you doing like a a man cave or [patient] yeah yeah that's exactly right [doctor] that is awesome great well that sounds like fun i hope you get to set it up just the way you you would like for your man cave to be so congratulations to you there so tell me have you experienced any kind of numbness in your arms or in your hands [patient] no no numbness or tingling [doctor] okay alright so let's just go ahead and do a quick physical exam on you here i did review your vitals everything here looks good now lem me take a look at your shoulder alright now on your left shoulder exam you have limited active and passive range of motion and how does that feel here [patient] that hurts [doctor] okay sorry there is tenderness of the greater tuberosity of the humerus but there is no tenderness at the sternoclavicular or acromioclavicular joints you have good hand grips alright and then now on your neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is intact to light touch alright so what does that all mean well firstly lem me go ahead and take a look at your results of your shoulder x-ray here now i reviewed the results and there are no fractures so that's good so let's go ahead and talk about my assessment and plan here wayne so for your problem of left shoulder pain your symptoms are most likely due to a rotator cuff tendinopathy so this means that you injured the tendons of the muscles that help make up your shoulder muscles so i will be ordering an mri for your left shoulder to be sure that there is nothing else going on with your shoulder okay [patient] okay [doctor] now i'm also going to refer you to physical therapy for approximately six to eight weeks and during that time you may also continue to take tylenol now if your symptoms do n't improve we can consider a steroid injection for your shoulder which can provide some relief do you have any questions about your plan at all [patient] so do you think this pain will ever go away [doctor] now well many patients are very successful with the physical therapy those will those help strengthen you know they do a lot of strengthening exercises with you to help strengthen you know your muscles so that it's not your movements not always relying on those joints predominantly so we're gon na go ahead and start with that and then see how you do okay [patient] okay okay [doctor] alright okay well do you have any other questions for me [patient] no i think that's it [doctor] okay well i'm gon na have the nurse check you out and she's also gon na give you some educational materials on the physical therapy and what to expect and and then go ahead and schedule a follow-up visit with me as well after you you do your physical therapy okay [patient] okay [doctor] alright well have a good day [patient] okay you too [doctor] thanks [patient] okay bye

ASSESSMENT

Left shoulder pain, most likely due to rotator cuff tendinopathy.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that his symptoms are most likely due to rotator cuff tendinopathy. I recommend obtaining an MRI of the left shoulder to further assess the rotator cuff. I will also refer him to formal physical therapy to strengthen his left shoulder for approximately 6 to 8 weeks. The patient was provided with educational materials regarding expectations related to his physical therapy. He may continue to take Tylenol as needed. If his symptoms do not improve with physical therapy, we will consider a steroid injection to the left shoulder. All questions were answered.


[doctor] hi teresa what's going on i heard that i heard that you're having a sore throat you're not feeling well [patient] yeah my throat has been hurting me for like four four days now and i think i had a fever last night because i was really sweaty but i did n't take my temperature because i was already in bed [doctor] okay alright so four days ago you started feeling badly okay now were you having chills [patient] yeah last night i was chills and i had lot of sweating and it's really hard to swallow [doctor] it's really hard to swallow okay now do you have pain every time you swallow or is it just periodically [patient] every time i swallow i'm even having trouble eating i can drink okay the like really cold water feels good [doctor] okay that's what i was gon na ask you okay so you're able to drink water and are you able to drink any other fluids have you been able to drink any you know i do n't know juices or milk shakes or anything like that [patient] well besides my wine at night i really just drink water all day [doctor] okay well i like to drink wine too what's your favorite type of wine [patient] peanut grooves yes [doctor] it's a good one i like that too i am also a pino navar fan so there you go alright well let's now do you feel sick to your stomach at all [patient] no i have a little bit of a stuffy nose not too bad it's really just my throat but i think my tonsils are swollen too [doctor] and your tonsils are swollen too now has anyone else sick in your household [patient] i do have little kids that go to school so they've always got you know those little runny noses or cough but nobody is really complaining of anything [doctor] okay alright now have you had strep throat in the past [patient] when i was a kid i had strep throat but i have n't had anything like that as an adult [doctor] okay alright and what do you do for work [patient] i i work as a cashier in a supermarket [doctor] okay alright and did you get your covid vaccine [patient] yep i did get my covid vaccine but it really made me feel sick so i'm hoping i do n't have to get another one later this year [doctor] okay did so you just got the two vaccines you did n't get the booster [patient] no i did n't get the booster because i really have n't had time to feel that sick again it really knocked me down for like two days and with the little kids it's really hard [doctor] okay alright well i saw that they did a rapid covid test when you came in here and that was negative so that's good so you do n't have covid which is which is good now let's talk a little bit about your hypertension and hypertension since i have you here did you ever buy that blood pressure cuff that i asked you to buy [patient] yes i did i blood the blood pressure cuff and my blood pressure is like all over the place sometimes it could be like one twenty for the top number sometimes it could be one forty for the top number i i do n't really remember the bottom number though [doctor] okay that's okay are you taking the lisinopril i think we have you on twenty milligrams a day [patient] yep i take it every morning with my multivitamin and my vitamin d [doctor] okay alright and are you watching your salt intake [patient] i really like my chips with my wine [doctor] is n't that the best we we could get along really well outside of here alright and then tell me a little bit about your diabetes now are you are you watching your blood sugars are you taking them at home [patient] sometimes i take that all that often again that could be all over the place sometimes i get if i take it first thing in the morning it'll be like eighty or ninety but at night sometimes it could be one forty [doctor] okay alright and i are you still taking the metformin we have you on a thousand milligrams twice a day [patient] uh uh yes i do take it i take it with my breakfast and with my dinner [doctor] okay alright great alright now are you are you a meds fan or a yankie's fan or god for a bit of filly's fan [patient] nope [doctor] no [patient] no do n't do n't like sports [doctor] do n't like sports just the wine [patient] no [doctor] okay alright well let's go ahead i wan na just do a quick physical exam now i'm gon na be calling out some of my findings and i'm gon na let you know what that means when i'm done okay so looking here first at your vital signs your vital signs look pretty good you do have a low-grade fever of about a hundred . four right now but otherwise your blood pressure is pretty good it's about one thirty two over eighty and your heart rate is eighty four now that looks pretty good so i'm just gon na go ahead and examine you so on your facial exam i'm gon na just press on your face here does this hurt [patient] no not no it does n't bother me [doctor] okay on facial examination the patient has no pain to palpation of the frontal or maxillary sinuses on nasal examination there is edema and erythema of the nasal turbinates bilaterally with associated clear discharge open up your mouth and say [patient] ah [doctor] on throat examination there is bilateral erythema and edema of the peritonsillar space with exudates present bilaterally the uvula is midline on your neck exam i do appreciate some cervical lymphadenopathy on the right hand side on your lung exam your lungs you have some coarse rhonchi at the bases that clear with cough and on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur or or rub so what does all of that mean teresa so all of that means is that yes you're showing signs of what we call an upper respiratory infection and i'm concerned that you might have some strep in the back of your throat based on the findings so let's just talk a little bit about my assessment and plan for you okay so for your first problem of your sore throat i'm gon na go ahead and have the medical assistant come in and swab you for a rapid strep test and if that's positive i wan na go ahead and place you on or prescribe amoxicillin five hundred milligrams three times a day for ten days and i'm gon na give you some lidocaine swish and swallow so that will help with some of the pain and you can take some ibuprofen as needed which will also help with the pain and some of that fever okay i do want you to go ahead and continue to to hydrate as much as possible what kind of questions do you have about that [patient] no that sounds good i just wanted to be sure i was okay because of the little kids [doctor] sure now for your next problem of your hypertension i wan na go ahead and order a lipid panel on you and i think i do wan na increase i do wan na increase the lisinopril to forty milligrams once a day just to get your blood pressure under better control and we'll see how you do on the forty milligrams once a day for your third problem of your diabetes let's go ahead and order a hemoglobin a1c and just to make sure that we do n't have to make any adjustments to your metformin how does that sound [patient] sounds good [doctor] any questions [patient] nope that's everything [doctor] okay bye good to see you i'll be in touch

ASSESSMENT AND PLAN

1. Sore throat.
 - Medical Reasoning: The patient has experienced sore throat, fever, chills, profuse sweating, and difficulty swallowing for 4 days. There is erythema and edema of the peritonsillar space with exudates present bilaterally as well as edema and erythema of her turbinates, bilaterally.
 - Patient Education and Counseling: We discussed treatment options today. I have stressed the importance of hydration.
 - Medical Treatment: We will perform a rapid strep test today. If she is positive for strep, I will prescribe amoxicillin 500 mg 3 times a day for 10 days. Prescription for lidocaine swish and swallow provided for pain relief. ibuprofen can also be taken for pain and fever relief.

 2. Hypertension.
 - Medical Reasoning: The patient states her blood pressure fluctuates often. Her blood pressure today in office was 132/80 mm Hg. - Patient Education and Counseling: We discussed treatment options including increasing her lisinopril and diet modifications.
 - Medical Treatment: Lipid panel ordered. Prescription for lisinopril 40 mg once a day is also provided.

 3. Diabetes.
 - Medical Reasoning: The patient’s blood sugar fluctuates between 80 to 90 in the morning to 140 in the evening. She is already at 1000 mg of metformin twice a day, which she does take with meals.
 - Patient Education and Counseling: We discussed the importance of achieving a healthy lifestyle and what effects that can have on her diabetes.
 - Medical Treatment: I have placed an order a hemoglobin A1c.


[patient] alright thanks for coming in today i see on my chart here that you had a bunch of lower respiratory infections so first tell me how are you what's going on [doctor] you know i'm doing better now but you know last week i was really sick and i just have had enough like i was coughing a lot a lot of mucus even had some shortness of breath and even a low-grade fever [patient] wow that is a lot so what did you do for some of those symptoms [doctor] you know i ended up drinking a lot of fluid and taking some robitussin and i actually got better over the weekend and now i'm feeling much better but what concerns me is that i i tend to get pneumonia a lot [patient] okay so when you say a lot like how frequently does it occur i would say it seem honestly it seems like it's every month or every other month especially over the past six six months that i just keep getting sick and i usually will end up having to go to my primary care doctor or [doctor] urgent care and i'll get prescribed some antibiotics and one time i actually ended up in the emergency room [patient] wow and how long do your symptoms normally last for [doctor] you know it could be as few as like a couple of days but sometimes it could go even up to a week [patient] mm-hmm you mentioned that you are a farmer did you do you notice that your symptoms occur while doing certain things on the farm [doctor] you know i was trying to think about that and i've been working on the farm for some time but the only thing i can think about is that i've been helping my brother out and i've been started like unloading a lot of hay which i do n't usually do and i wan na say that my symptoms actually start the days that i'm unloading hay [patient] alright do you wear a mask when you're unloading hay [doctor] no i do n't do that [patient] okay [doctor] none of us do [patient] okay yeah so like that your brother does n't either [doctor] no i'm the only one who seems to be getting sick [patient] alright so i know you said you were trying to like help out your brother like what's going on with him [doctor] you know we've just been getting really busy and so he has been working around doing other things so i've just been helping him just cover the extra load [patient] mm-hmm okay alright do you have any other siblings [doctor] yeah there is actually ten of us [patient] wow okay that's that's a lot of siblings [doctor] yeah i'm okay [patient] maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place [doctor] yeah we do n't need to hire any i mean have anyone else this is our family [patient] you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies [doctor] no no i have never had any problems with allergies [patient] okay and do you smoke [doctor] i do n't smoke [patient] do you live with anybody who does [doctor] i do not [patient] okay alright so okay so now i i wan na go ahead and do my physical exam i'm gon na call out some of my findings just to make sure that i'm documenting everything and if you have any questions about what it is that i'm saying please feel free to ask okay [doctor] okay [patient] so i reviewed your vitals and you appear to be breathing a little fast your respiratory rate is twenty but but your oxygen is you're satting kind of fine at ninety nine percent on room air so i'm not too worried about that on for on your heart exam i do you have a regular rate and regular rhythm i do not appreciate any murmurs rubs or gallops on your lung exam you know i do you do have some fine rales on your lung exam but no wheezes and on your musculoskeletal exam i do not appreciate any clubbing of your fingers so for your results i did review the results of your chest x-ray and i noticed some round glass opacities so let me tell you a little bit about like my assessment and plan for your first problem of recurrent lung infections your symptoms seem consistent with a condition we call hypersensitivity pneumonitis in your case another name is farmer's lung which you know is appropriate considering your job this could be caused by bacteria and or mold that is found in the hay when you inhale it it leads to an allergic reaction in your lungs this is why your symptoms occur every time you move hay for your current symptoms i'm gon na prescribe you a a course of an oral steroid this will help to decrease the inflammation that is occurring in your lungs i will also be ordering a cat scan of your lungs which will help confirm the diagnosis as as well a pulmonary function test to assess how severe your respiratory impairment is it would be best if you could eliminate your exposure to the hay or prevent further to prevent further damage to your lungs however if you are unable it's very important that you wear a respirator when moving hay around i know that that was a lot of information i think it boils down to pull in more of your siblings to help work around but do you have any questions [doctor] yeah so is this gon na help so i do n't keep getting sick [patient] so ideally what we are doing i think this is the best course of action to deal with the deeper problem right of these infections and to kind of like clear up the pneumonia everything seems to hint on so what we're gon na do is treat your current infection we're going to either prevent you from being around hay or make it so that it's safe for you to be with hay and then we're gon na see like what we need to do moving forward does that help [doctor] okay it does [patient] alright [doctor] thank you [patient] okay no problem [doctor] alright

ASSESSMENT AND PLAN

1. Recurrent lung infections.
 - Medical Reasoning: The patient's symptoms seem consistent with hypersensitivity pneumonitis. He is a farmer and has been moving hay quite frequently recently.
 - Patient Education and Counseling: The nature of the diagnosis was discussed with the patient. I explained that hypersensitivity pneumonitis could be caused by bacteria and/or mold that is found in the hay. We discussed that when inhaling this, it leads to an allergic reaction in the lungs, which would explain why symptoms occur every time he moves hay. He was advised that it would be best to eliminate his exposure to hay in order to prevent further damage to his lungs, however, if he is unable to do this then it would be recommended that he wear a respirator when working. Questions were invited and answered today.
 - Medical Treatment: A course of oral steroids were prescribed today to help decrease his lung inflammation. CT of the lungs will also be ordered today to confirm the diagnosis. A pulmonary function test was also ordered to assess the severity of his respiratory impairment.


[doctor] hey matthew i see here that you've had some back pain for a while and your pcp sent you over to see me how're you doing today [patient] pretty good i'm feeling pretty good do n't like the weather you know i've been sitting in the waiting area for you know thirty minutes and that definitely makes the symptoms worse [doctor] okay well first of all i i agree with you the weather has kinda been all over the place been hot and been cold and and and now it seems like we've had a week of pretty chilly weather hopefully that changes pretty soon so tell me a little bit about when when your back pain started and and and what happened there [patient] well you wan na hear the long story or kind of the short story because my back has been bothering me for a long time [doctor] so let's do let's do the reader's digestive version [patient] well i ca n't i ca n't really tie my shoes you know standing really makes it bad you know when i go to the mall it really really i do n't know all i i've just been bedridden [doctor] okay and i know it got real bad about a month ago that's what the report here from the pcp said but can you tell me exactly where the pain is in your lower back can you kinda point to where that's at [patient] yeah it's right here and you know like thirty years ago when i fell off the roof it was really really bothersome they they said maybe there was a fracture or something and you know i do n't know i just could n't play football and then i had to you know kinda try to take care of myself but you know it's it's been really bad for about a month [doctor] okay and then do you still have that pain that radiates down your left leg sometimes [patient] yeah of course yeah it goes all the way through here [doctor] okay and then so it looks like you pointed to your lower back area and then pointed down through your hip and down into your to your left leg can you describe that pain for me [patient] it's like a electrical tooth ache and it it it goes down the whole leg [doctor] okay and can you rate that pain for me right now zero being none ten being the worst pain you've ever been in in your life [patient] right now it's less bad i did n't take my medications because i wanted you to see me as as i am but it's six out of ten but when it gets really bad i'd say it's thirteen out of ten [doctor] okay and anything that you do make it feel better you mentioned that you know sometimes sitting or laying down anything there make that better [patient] yeah like i said it the only thing that seems to make it better is laying down [doctor] okay [patient] you know standing walking seems to make it worse coughing sneezing makes it worse and you know i had a friend that saw you and you know you burned some nerves or something like that and so i was just seeing if there was something that you could do to get me out of this pain and hopefully you can do it today [doctor] okay and then any numbness or tingling in in your lower extremities or any weakness there in your legs [patient] you know it it's my back that's weak and my legs are weak both of them you know coughing sneezing seem to make it worse so sorry i'm just trying to be like a typical patient because most patients they do n't answer the darn questions so you you know all this time i still have n't gotten a chief complaint out of them so i love the way that you're trying to redirect and so you know what your doctor said you had back pain and leg pain but for me the most important thing for me to capture is that it's in the hip side of the leg side of the calf goes to the big toe and so i need them to be able to give me a perfect sort of root signature so i can hone in is that four five disk seen on the mri really significant or is it on the opposite side but again i'm sorry i'm purposely trying to be in a difficult patient because some of these patients he asked them fifty different questions they wo n't answer any of them so anyway sorry about well [doctor] that's okay [patient] to explain but this is what i deal with every single day [doctor] absolutely [patient] lot of pain yeah you know what my pain is eight out of ten it goes in the back goes into the hip side of the leg side of the calf goes to the big toe my foot kinda drags when i walk i've been having to use a cane nothing seems to make it better and but very few patients will give you the perfect history and most people will start talking about you know when something happened or go back to thirty years ago and you wan na redirect them to their current symptom but the patients wo n't rarely ever tell you what the chief complaint is you you got ta pull it out of them [doctor] so let's take a a quick look at you here okay let's do a physical exam real quick so your vitals look good which is a good thing now on your back exam i do n't see any bony abnormalities no redness or no and no bruising present now do you have pain when i press here [patient] no it's right here [doctor] okay so positive for pain to palpation at the l4 vertebrae and if you bend forward do you have pain there [patient] it hurts all the time especially sitting in these run office desks [doctor] okay so you are positive for pain with flexion and extension of your back i'm going to go ahead and test the strength of your legs now push out against my hands for me please [patient] okay that's it that's all i got [doctor] alright so four out of five strength in the left and five out of five on the right does look like that reflexes are brisk and motor and sensory is intact in both lower extremities i do wan na review the results of your mri the mri shows a disk herniation at the level of l4 l5 vertebrae and it is associated with some nerve root impingement and what that means is the nerve is being compressed by that herniation so let me tell you a little bit about my assessment and plan okay so for the diagnosis of of acute disk herniation at l4 l5 with that nerve root impingement that's causing that pain down your leg and your lower back pain now i know you've tried nsaids in the past without relief and you've done some pt so what i'm going to do is i'm gon na recommend an epidural steroid injection and we're gon na do that today for you if you agree to it what that means is gon na place some anti-inflammatory medication right at the spot of inflammation and once that's in place i wan na refer you back to pt and we wan na strengthen that area mkay you're young and otherwise healthy i think you'll do well but it can take about two to three weeks for that injection really to take full effect so then i want you to see pt and i want you to see me again in about a month are you okay with that treatment plan [patient] sure sounds good [doctor] alright sounds good i'm gon na have the nurse come in and get you prepped and then we'll get that injection for you

ASSESSMENT

Acute disc herniation at L4-5 with nerve root impingement.

PLAN

I have recommended that we treat the patient conservatively with a epidural steroid injection and formal physical therapy. With the patient's consent, we will proceed with a epidural steroid injection into the lumbar spine today. He will follow up with me in 4 weeks to check on his progress."