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D2N055 | aci | [doctor] karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you
[patient] i'm okay i guess
[doctor] hey dad how are you doing
[patient] hey doc i am okay yeah karen has been having this eye twitch i noticed a couple of weeks ago when i talked to her pediatrician and they told me to come see you
[doctor] okay alright so karen have you felt the twitch
[patient] yeah well i mean i feel my face sometimes
[doctor] yeah and do you have any pain when it happens
[patient] no it it does n't really hurt but i noticed that dad looks real nervous when it happens
[doctor] yeah i i i can understand that's because he loves you do you feel the urge to move your face
[patient] sometimes and then it moves and then i feel better
[doctor] okay okay and so so dad how often are you seeing the twitch on karen
[patient] i do n't know i mean it varies sometimes i see it several times an hour and there is other days we do n't see it at all until sometimes late afternoon but we definitely notice it you know everyday for the last several weeks
[doctor] okay so karen how is how is how is soccer
[patient] i like soccer
[doctor] yeah
[patient] yeah dad dad takes me to play every saturday
[doctor] okay
[patient] it's it's pretty fun but there's this girl named isabella she she plays rough
[doctor] does she
[patient] she yeah she tries to kick me and she pulls my hair and
[doctor] oh
[patient] sometimes she's not very nice
[doctor] that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson
[patient] yeah and and then sometimes after soccer we we go and i get mcdugge's and it and it's it makes for a nice day with dad
[doctor] is that your favorite at mcdonald's in the the mcnuggates
[patient] not not really but they are cheap so
[doctor] okay alright well you you made dad happy at least right
[patient] yeah that's what he says because i'm expensive because i want dresses and dogs and stuff all the time
[doctor] yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens
[patient] no i mean when it happens she just continues playing or doing whatever she was doing when it happens
[doctor] okay alright has she has she otherwise been feeling okay since this started has she been acting normally
[patient] i i'd say she seems fine i mean she has been eating well and playing with her friends and she goes about her normal activities really
[doctor] okay good
[patient] never even though anything was going on
[doctor] okay alright good so has has karen had any seizures in the past
[patient] no
[doctor] no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching
[patient] well no uh it's just her face
[doctor] okay
[patient] i mean the whole side of her face moves when it happens it seems like it several seconds and then it finally stops and she just seems to be blinking frequently and and and you know wait a minute i i did make a video so you can see just in case it does n't do it during the visit
[doctor] okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome
[patient] well no history of seizures but i i i never heard of that tourette thing
[doctor] yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger
[patient] really i had nobody in our family got anything like that
[doctor] okay now tell me have you noticed any other symptoms how about like fever or chills
[patient] no
[doctor] okay coughing headache
[patient] ma'am
[doctor] okay how about any problems with karen's sleep
[patient] nope
[doctor] okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay
[patient] okay
[doctor] alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there
[patient] mm-hmm
[doctor] does that feel the same
[patient] yeah
[doctor] okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator drift sensation is intact reflexes are two plus and symmetric at the biceps triceps knees and ankles so this means everything looks good karen
[patient] that's great
[doctor] good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school years and tics can also include things like shoulder shrugging facial grimacing sniffling excessive throat clearing and uncontrolled vocalization i can say that essentially they're brief sudden and involuntary motor movements now we do n't have a full understanding of the cause of the tics but they typically occur around five to ten years of age but most ticks go away on their own and they disappear within a year so these are what we call transient tics and the best thing to do is ignore the tics so it does n't seem to be bothering karen and she seems to be doing well in school and activities so it may wax and wane over time but you might notice it more towards the end of the day when the child is tired so you may also you know see it if they're stressed so that's why it's important to just ignore it now when you draw attention to the tick it does make the child conscious so that can make the tic worse so we want to be careful again just to to kind of not to draw too much attention on it and do you have any questions for me
[patient] so you mean you're telling me you do n't think he had a seizure or a bit or nothing
[doctor] yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards
[patient] so you're not recommending any kind of treatment there is no pill or cream or nothing
[doctor] not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay
[patient] alright alright sounds good
[doctor] alright thank you you guys have a good day
[patient] doctor
[doctor] bye karen | CHIEF COMPLAINT
Right eye twitch.
SOCIAL HISTORY
The patient plays soccer every Saturday, however she has noted that there is a girl that tries to kick her and pulls her hair.
FAMILY HISTORY
Patient's father reports that they do not have a family history of seizures or Tourette's syndrome.
REVIEW OF SYSTEMS
Constitutional: Denies fever, chills, or changes in appetite.
Eyes: Reports right eye twitch. Denies right eye pain.
Respiratory: Denies cough.
Neurological: Denies headaches or sleep disturbances.
PHYSICAL EXAM
Neurological
- Orientation: Alert and oriented x3. Speech is clear and fluent. Gait is steady. Heel toe walking is normal. Cranial nerves grossly intact without focal neurologic findings. No pronator drift. Sensation is intact. Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles.
ASSESSMENT AND PLAN
1. Transient tics.
- Medical Reasoning: The patient's father provided a video today as she did not have a twitch in office. It appears the patient is experiencing a tic.
- Patient Education and Counseling: Nature of the diagnosis was discussed today with the patient and her father. I advised eye tics are very common in children and as many as 1 in 5 children have a tick during their school years. We discussed tics can also include things like shoulder shrugging, facial grimacing, sniffling, excessive throat clearing, and uncontrolled vocalization. I explained that essentially they are brief, sudden and involuntary motor movements and that we do not have a full understanding of the cause. We also discussed that they typically occur around 5 to 10 years of age and mostly resolve on their own within a year. Dad was advised that treatment is not recommended as they do not appear to be bothering Karen and she continues to do well in school and activities. Additionally, we discussed avoiding drawing attention to the tic as it may cause Karen to feel self-conscious and increase the severity of the tic.
- Medical Treatment: None at this time.
Patient Agreements: The patient's parent understands and agrees with the recommended medical treatment plan.
All questions were answered. |
D2N056 | aci | [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 | CHIEF COMPLAINT
Recurrent lung infections.
SOCIAL HISTORY
Patient reports he is a farmer. He denies smoking or living with anyone who smokes.
ALLERGIES
Patient denies history of seasonal allergies.
REVIEW OF SYSTEMS
Constitutional: Reports low-grade fever.
Respiratory: Reports shortness of breath and productive cough.
VITALS
Respiratory rate: 20 breaths per minute.
Pulse oxygenation: 99 percent on room air.
PHYSICAL EXAM
Respiratory
- Auscultation of Lungs: Some fine rales were noted.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.
Musculoskeletal
- Examination: No clubbing.
RESULTS
X-ray of the chest was reviewed today and shows some round glass opacities.
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.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N057 | aci | [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 | CHIEF COMPLAINT
Right great toe pain.
HISTORY OF PRESENT ILLNESS
Joseph Walker is a pleasant 58-year-old male who presents to the clinic today for the evaluation of right great toe pain. The onset of his pain began 2 weeks ago, however it worsened last week. He noticed the pain worsening when he was at a trade show convention and he could not ambulate as he was forced to stand there as the pain was there the whole time. He denies any specific injury. The patient describes his pain usually as throbbing and burning, but notes it occasionally changes to sharp, stabbing pain especially with movement or prolonged ambulation. His symptoms also include redness to the right great toe. The patient states that he has been ambulating on his heel to keep his toe from bending. He reports that his pain is present even with the slightest of pressure, which he notes is worse at night when his sheet is touching his right toe. He adds that he has been taking 2 ibuprofen per day, which does not provide him with relief.
SOCIAL HISTORY
Patient reports that he likes to bicycle ride.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right great toe pain.
Skin: Reports redness.
PHYSICAL EXAM
MSK: Examination of the right great toe reveals 10 degrees of plantar flexion with pain. Pain to palpation of the right great toe, between the big toe and 2nd toe. Palpated a bone spur on the right great toe.
RESULTS
X-ray of the right great toe taken today in office reveals a large bone spur on the anterior aspect of the right great toe joint. There is a loss of cartilage with some arthritis present.
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.
INSTRUCTIONS
The patient will follow up with me in 2 weeks to check on his progress. If his pain does not improve with the orthotics, I will recommend a cortisone injection or surgical intervention. |
D2N058 | aci | [doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced ejection fraction ejection fraction thirty five percent and moderate mitral regurgitation alright russell hi how are you doing today
[patient] hey document i i do n't know i'm doing alright i guess
[doctor] just alright how's it
[patient] well
[doctor] how's it been since you've had your heart attack have you been have you been doing alright
[patient] no i've been seeing you for years since i had my last heart attack in two thousand eighteen but i've been doing pretty good i ca n't believe this happened again i mean i'm doing okay i guess i just feel tired every now and then and but overall i mean i guess i feel pretty well
[doctor] okay good were you able to enjoy the spring weather
[patient] yeah some i mean i'm hoping now that i've had my little procedure that i'll feel better and feel like getting back out and and maybe doing some walking there is some new trails here behind the rex center and maybe get out and walk those trails
[doctor] that will be fine i know you love walking the trails i know you like looking at the flowers because i think you you plant a lot of flowers as well do n't you especially around this time
[patient] yeah i do some gardening around the house
[doctor] yeah
[patient] and you know i really like photography too being able to go out and take nature pictures
[doctor] yeah
[patient] so i'm hoping to be able to go out and do that
[doctor] okay well we'll we'll do what we can here to get you out and going doing all those fun activities again now tell me have you had any chest pain or any shortness of breath
[patient] no not really no chest pain or shortness of breath i've been doing some short walks right around the house so like around the block
[doctor] okay
[patient] but i stay pretty close to the house i've been doing some light housekeeping and i do n't know i seem to be doing okay i think
[doctor] okay alright now tell me are you able to lay flat at night when you sleep or
[patient] well i mean i i never have truly laid flat on my back i've always slept with two pillows which is normal for me
[doctor] okay
[patient] so i mean i guess i really do n't have any troubles with my sleeping
[doctor] okay good how about are your legs swelling up
[patient] nope i've always i always had skinny ankles like like i got dawn knots legs
[doctor] well that's cute were you able to afford your medications and are you taking them as prescribed
[patient] yeah i've been taking my medicine i got pretty good insurance there through the plant and and so the co-pay is n't too bad
[doctor] okay
[patient] and i've been taking them because i do n't want my sense to close up and they told me that that to take them this you know all the time and and i've been taking them since i got out of the hospital
[doctor] okay well very good i'm glad you're doing that good for you russell and and then please keep that up now tell me are you watching your salt intake and trying to change your diet
[patient] yeah so when i was in the hospital they said something about my way my heart pumps now
[doctor] mm-hmm
[patient] it it's it's a little low and i might keep fluid on my legs if i'm not careful
[doctor] right
[patient] and it's gon na be hard because you know i i really do like pizza and and they told me that i'm really gon na have to watch salt and they said that there is a lot of salt and pizza
[doctor] there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay
[patient] well
[doctor] alright so why do n't we go ahead and do a quick physical exam on you here i just want to take a look at you your vital signs look good i'm glad to see you're tolerating the medication well i'm gon na go ahead and feel your neck here i do n't appreciate any jugular venous distention and there are no carotid bruits on your heart exam there is a three out of six six systolic ejection murmur it's heard at the left base but that's pretty much the same as last year so we'll continue to monitor that okay let me listen to your lungs here real quick russell your lungs are clear so good good and your extremities i do n't see any swelling or edema on your right radial artery the cath site there is clean and it's dry and intact and i do n't see any hematoma so that's good and there is a palpable rra pulse so russell i did review the results of your ekg which showed normal sinus rhythm good r wave progression and evolutionary changes which are anticipated so let's go ahead and talk about my assessment plan for you for your first diagnosis of coronary artery disease we are gon na have you continue your your aspirin eighty one milligrams daily and brilinta ninety milligrams twice daily and we're gon na have you continue on that high dose statin that atorvastatin you might call it lipitor eighty milligrams daily and then also continue on that toprol fifty milligrams daily okay and i'm also going to refer you to cardiac rehab so for you to get some education about your heart and also give you the confidence to get back exercising regularly now i know patients love the cardiac rehab program i think you will do well does that sound good to you
[patient] that sounds good document
[doctor] alright so for your second diagnosis here the newly reduced left ventricular dysfunction and moderate mitral regurgitation i think your pumping function will improve in time you know they got you to the lab quickly so i think that heart muscle is just stunned and you're very compliant you're very good with your medications and following through with those so i think it will recover so that said i want you to go ahead and continue continue your lisinopril twenty milligrams a day i do n't think you need a diuretic at this time but i do want to add aldactone twelve . five milligrams daily and then you'll need to get labs next week okay and then we're gon na repeat another echocardiogram echocardiocardiogram in about two months
[patient] okay
[doctor] okay and then for your hypertension your third diagnosis of hypertension i want your to take your blood pressure just like you would you know every so often and then because your blood pressures actually seem fine at this time so we will continue to monitor that and i think you will tolerate the aldactone well as well
[patient] alright sounds good document
[doctor] okay well you take care and you have a good evening
[patient] yeah you too
[doctor] bye | CHIEF COMPLAINT
Hospital follow-up after an anterior STEMI.
MEDICAL HISTORY
Patient reports history of CAD status post prior RCA stent in 2018, hypertension, and diabetes mellitus.
SURGICAL HISTORY
Patient reports history of RCA stent in 2018 and most recently underwent drug-eluting stent placement in the LAD.
SOCIAL HISTORY
Patient reports enjoying walking outside, gardening, and nature photography.
MEDICATIONS
Patient reports taking aspirin 81 mg daily, Brilinta 90 mg twice a day, Lipitor 80 mg daily, Toprol 50 mg daily, and lisinopril 20 mg a day.
REVIEW OF SYSTEMS
Constitutional: Reports fatigue. Denies changes in sleep.
Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Musculoskeletal: Denies lower extremity swelling.
VITALS
Vital signs look good today.
PHYSICAL EXAM
Neck
- General Examination: No carotid bruits.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: Grade 3/6 systolic ejection murmur, heard at the left base.
Musculoskeletal
- Examination of the right upper extremity reveals no swelling or edema on the right radial artery. Cath site is clean, dry, and intact. No hematoma. Palpable right radial artery pulse.
RESULTS
Electrocardiogram is reviewed and revealed normal sinus rhythm with good R wave progression and evolutionary changes, which are anticipated.
ASSESSMENT AND PLAN
1. Coronary artery disease.
- Medical Reasoning: The patient's exam is consistent with coronary artery disease.
- Patient Education and Counseling: We discussed that he should continue to watch his diet and salt intake. We also discussed that the cardiac rehab should help with his confidence with exercising regularly and for his education.
- Medical Treatment: Continue taking aspirin 81 mg daily Continue taking Brilinta 90 mg twice a day. Continue taking Lipitor 80 mg daily. Continue taking Toprol 50 mg daily. I will refer him to cardiac rehab.
2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.
- Medical Reasoning: The patient's physical exam is consistent with this diagnosis.
- Patient Education and Counseling: We discussed that his pumping function should improve in time. We also discussed that since he is compliant with his medications and presented to the cardiac cath lab quickly, he should recover. I advised the patient that he does not need to start a diuretic at this time.
- Medical Treatment: Continue taking lisinopril 20 mg a day. Prescription for Aldactone 12.5 mg daily provided. Order for labs provided. Repeat echocardiogram ordered to be completed in 2 months.
3. Hypertension.
- Medical Reasoning: This seems stable at this time.
- Medical Treatment: Continue home blood pressure monitoring.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N059 | aci | [doctor] okay
[patient] good morning
[doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it
[patient] sure absolutely what can i help you with today
[doctor] so you know i've been dealing with my asthma and like i tried to join sports but it's really kind of it's getting hard you know and i i i just wonder if there's something that can be done because i really do like playing water polo
[patient] but i'm having difficulty breathing sometimes i've had to like you know stop matches and sit on the side just to kind of like catch my breath and use my inhaler so i was wondering if there was something we could do about it
[doctor] and then like i'm kind of a little bit worried i think my mood is getting a little a little worrisome and i i wanted to explore like what my options were
[patient] okay let's talk about the asthma first so what inhaler are you using now
[doctor] i have an albuterol inhaler
[patient] okay and when when you're having trouble it's usually just around sports that is it keeping you up at night
[doctor] so i do n't really like wake up at night a lot typically like it's sports like you know if i'm doing anything like crazy aerobic or like running or anything i do notice that if any if i'm around smoke i do start coughing a little bit but most of the time it's sports
[patient] okay and can you describe a little bit for me what happens
[doctor] i start to yeah no so i start to feel like there is like some phlegm building up in my in my throat and i start coughing like my chest gets tight i start wheezing and i just have to sit down or else i'm gon na get like lightheaded too
[patient] okay and then when you use your inhaler
[doctor] mm-hmm
[patient] does it does it alleviate the problem
[doctor] so yeah it helps with that like phlegm feeling you know but i still i still have to sit down you know and like breathe and then the thing that i hate about that inhaler is i start getting like shaky is that supposed to be happening
[patient] yes that is unfortunately normal and a side effect with the inhaler
[doctor] okay
[patient] so you use you're using two puffs of the inhaler
[doctor] mm-hmm
[patient] for the symptoms
[doctor] yes
[patient] and then you sit down and does it does it get better within about fifteen minutes or so
[doctor] yeah yeah it does but you know i had to like step out of the the pool to make that happen i'm hoping that there is something else we can do okay have you ever taken any daily medications for your asthma an inhaler or singulair or anything like that no i i just use my inhaler whenever i have an attack
[patient] okay so that's something we might wan na consider but how often is it happening
[doctor] pretty much every time i do any kind of aerobic workout
[patient] okay and outside of physical activity you're not having any problems
[doctor] yeah there's that part where like if i'm around somebody who has been smoking a lot or is currently smoking but i usually just step away i do n't even like to be around them you know that makes sense
[patient] alright well we will look at that tell me about the mood issues you are having
[doctor] yeah so one of the reasons i got into like trying to get into sports is like i feel like you know you you feel a lot more energized and a lot you know happier but like lately i've just been kinda stressed out you know like i have i have like sats that i need to study for i've got like all these ap classes you know there's just it i feel like there's a lot of pressure and you know like i get it but there are times where i'm just like really down and i i do n't really know what else i can do
[patient] okay that makes sense any any difficulty with focusing or you're having difficulty retaining information or is it more feeling sad not having motivation
[doctor] so i think it's like a lot of sadness a lot of like you know i do n't really i kinda feel like you know i do n't really like want to do anything you know my friends will go out and i'll just be like i'd rather be at home i am really tired a lot too
[patient] okay alright well let me let me go ahead and check you out
[doctor] mm-hmm
[patient] and then we can talk a little bit more
[doctor] okay
[patient] i'm gon na take a listen to your heart and lungs
[doctor] mm-hmm
[patient] and everything sounds good
[doctor] let me take a look at your eyes
[patient] mm-hmm and in your ears everything looks okay have you had any problems with allergies you have seasonal allergies or anything like that
[doctor] yeah i think so yeah
[patient] i do see just a little bit of fluid in the ears
[doctor] mm-hmm
[patient] and i'm gon na look in your mouth too
[doctor] okay
[patient] and throat looks fine no tonsils
[doctor] mm-hmm
[patient] lem me go ahead and have you lay back on the table and i'll take a listen to your stomach
[doctor] okay
[patient] everything sounds okay i'm gon na feel around just to make sure everything feels normal
[doctor] mm-hmm
[patient] everything feels fine and i'm gon na check reflexes and they're all normal
[doctor] awesome
[patient] it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair
[doctor] mm-hmm
[patient] and start with that once you are on that daily and you can continue to use the albuterol inhaler those side effects unfortunately you're right it's it's just one of the expected side effects with an albuterol inhaler i would recommend just what you're doing just sit down for a little bit after you take it
[doctor] and we will get you started on the singulair probably within about a month you should see a difference so i will have you come back in about six weeks and follow up and see how you're doing with that
[patient] in terms of the mood is this new for you
[doctor] yeah i think so like when i started this year
[patient] and it sounds like related to school expectations and the stress with saps and all of that
[doctor] yeah
[patient] okay let's consider having you start seeing a therapist i think that would be a good place to start
[doctor] mm-hmm
[patient] and we will do some screening questionnaires and and then follow up in a couple weeks on that too
[doctor] okay alright sounds like a plan okay
[patient] thank you | CHIEF COMPLAINT
Asthma.
MEDICAL HISTORY
Patient reports history of asthma.
SURGICAL HISTORY
Patient reports history of tonsillectomy.
SOCIAL HISTORY
Patient reports she is a student and enjoys playing water polo as well as being active with aerobics and running.
ALLERGIES
Patient reports history of seasonal allergies.
MEDICATIONS
Patient reports using an albuterol inhaler, 2 puffs as needed.
REVIEW OF SYSTEMS
Constitutional: Reports fatigue.
Respiratory: Reports shortness of breath.
Psychiatric: Reports mood changes.
PHYSICAL EXAM
Ears, Nose, Mouth, and Throat
- Examination of Ears: Mild fluid in ears.
- Examination of Mouth: Normal.
- Examination of Throat: Tonsils have been previously removed.
Gastrointestinal
- Auscultation: Bowel sounds normal in all 4 quadrants.
Integumentary
- Examination: No rash or lesions. Normal capillary refill and perfusion.
- Palpation: No enlarged lymph nodes.
ASSESSMENT AND PLAN
1. Asthma.
- Medical Reasoning: The patient has experienced an increased need to use her albuterol inhaler. She is not currently utilizing a daily medication. At this time, we will try a daily medication since it looks like she might be having some allergies.
- Patient Education and Counseling: I explained the side effects of albuterol to the patient. We also discussed Singulair and that she should start to see a difference in her breathing within approximately 1 month.
- Medical Treatment: We will start her on a daily asthma medication. She can continue to use the albuterol inhaler. We will start her on Singulair in about a month.
2. Mood.
- Medical Reasoning: The patient reports being under a lot of stress with school. I believe this may be attributing to her mood.
- Medical Treatment: I would like for the patient to be seen by a therapist. She will also complete our screening questionnaire.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up in 6 weeks for recheck. |
D2N060 | aci | [doctor] hey jean how're you doing today
[patient] i'm doing alright aside from this foot pain that i have
[doctor] so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened
[patient] yeah so yeah i was playing in a soccer game yesterday and i was trying to steal the ball from another player and she ended up falling directly onto my right foot and i do n't know i i mean i was trying to get around her and my body ended up twisting around her and then i accidentally felt a pain in my foot
[doctor] okay so have you ever hurt your left foot before
[patient] no i've had a lot of injuries in soccer but never injured this foot
[doctor] okay and then so after the fall and the entanglement with the other player were you able to continue playing
[patient] no i had to stop playing right away and actually being helped off the field
[doctor] wow okay and what have you been doing for the the pain since then
[patient] so i've been keeping it elevated icing it the trainer wrapped it yesterday and taking ibuprofen as well
[doctor] okay alright so without any ibuprofen can you tell me what your pain level is
[patient] without ibuprofen i would say my pain is a three
[doctor] okay and then with your ibuprofen can you tell me what your pain level is
[patient] like a seven eight
[doctor] okay so how long have you been playing soccer
[patient] really since i was like four five i've been playing a long time
[doctor] well that's cool yeah we our our youngest daughter she is almost sixteen and she plays the inner marrial soccer league they are down at the rex center did is that where you started playing or did you guys did you start playing somewhere else
[patient] yeah just like this local town leak i started playing that way and then played all throughout school
[doctor] that's
[patient] high school teams
[doctor] that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation
[patient] no i have not
[doctor] okay now if it's okay with you i would like to do a quick physical exam i reviewed your vitals and everything looks good blood pressure was one eighteen over seventy two heart rate was fifty eight respiratory rate was fourteen you are afebrile and you had an o2 saturation of ninety nine percent on room air on your heart exam your regular of rate and rhythm do n't appreciate any clicks rubs or murmurs no ectopic beats noted there on auscultation listening to your lungs lungs are clear and equal bilaterally so you're moving good air i'd like to do a focused foot exam on your left foot so i do see some bruising on the bottom of your foot and on the top of your foot as well now there is associated swelling and i do appreciate tenderness to palpation of your midfoot and you are positive for the piano key test on a neurovascular exam of your left foot you have a brisk capillary refill of less than three seconds dorsalis pedis pulse is intact and strong and you do have motor and sensation that it's intact to light touch now i would like to do a review of the diagnostic imaging that you had before you came in so i do notice a subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space so lem me talk to you a little bit about my assessment and plan now for for the first concern of right foot pain your right foot pain is due to a lisfranc fracture which is a fracture to one of your second metatarsal bones at the top of your foot where the metatarsals meet your cuboids now there are ligaments at the top of your foot so i'm gon na be ordering an mri to assess for injury to any of these ligaments now based on your exam and from what i'm seeing on your x-ray you're most likely going to need surgery of that foot now the surgery will place the bones back in their proper position and using plates and screws will hold them there while they heal and this is gon na allow those bones and ligaments to heal properly it is a day surgery and you will be able to go home the same day and then i'm going to have you follow up with me here in the clinic you'll be in a cast and you will need to use crutches and you will not be able to use that left foot for about six to eight weeks now after that six to eight weeks you will gradually start walking on your foot based on how you tolerate it and we'll see how you do at that point so i do believe you're gon na need surgery i i'm recommending this because there are significant complications to your foot if we do not do this poor bone and ligament healing can lead to losing the arch of your foot and you're becoming flat-footed you also have a high likelihood of developing arthritis in that foot so what i'm gon na do unfortunately you'll be out the rest of the season but we are gon na get you fixed up and ready for next season if you're okay with all of this i'm gon na have the nurse come in and get you started on your paperwork and then i will see you on monday morning and we will get your foot taken care of
[patient] alright thank you
[doctor] you're welcome | CHIEF COMPLAINT
Left foot pain.
HISTORY OF PRESENT ILLNESS
Jean Martinez is a pleasant 27-year-old female who presents to the clinic today for the evaluation of left foot pain.
The patient sustained an injury to her left foot while playing soccer yesterday. She became entangled with another player, causing the player to fall onto the patient's foot, resulting in immediate pain. After the incident, she required help to get off of the field and was unable to participate for the rest of the game. Her trainer wrapped her foot, and she has tried ice, elevation, and ibuprofen to treat her symptoms. with medication, she rates her pain as 3/10, but without medication her pain is rated as 7-8/10. There is no numbness, tingling, or other abnormal sensations associated with her pain.
Of note, the patient has sustained several injuries in the past while playing soccer, but this is her first left foot injury.
MEDICAL HISTORY
The patient reports that she has sustained several soccer injuries in the past.
SOCIAL HISTORY
The patient has been playing soccer since she was 4 or 5 years old. She is currently playing in a local league.
MEDICATIONS
The patient reports that she has been taking ibuprofen.
REVIEW OF SYSTEMS
Musculoskeletal: Reports left foot pain.
Neurological: Denies left foot numbness or tingling.
VITALS
Blood pressure: 118/72 mmHg
Heart rate: 58 bpm
Respiratory rate: 14
Temperature: Afebrile
Oxygen saturation: 99% on room air
PHYSICAL EXAM
CV: Regular rate and rhythm without clicks, rubs, or murmurs. No ectopic beats noted on auscultation of the heart. Brisk capillary refill, less than 3 seconds. Dorsalis pedis pulse is intact and strong.
RESPIRATORY: Lungs are clear and equal bilaterally.
NEURO: Motor and sensation in the left foot are intact to light touch.
MSK: Examination of the left foot: Ecchymosis on the plantar and dorsal aspects of the foot. Associated swelling. Tenderness to palpation of the midfoot. Positive piano key test.
RESULTS
X-ray images of the left foot were obtained and reviewed today. These reveal subtle dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases. There is presence of a bony fragment in the Lisfranc joint space.
ASSESSMENT
Lisfranc fracture, left foot.
PLAN
I explained the nature of her injury in detail. Based on her exam and x-ray findings, she will most likely require surgery of the left foot, but I want to order an MRI to assess for any ligamentous injuries. We discussed the procedure and postoperative expectations, such as recovery time and restrictions, at length. We also discussed the complications associated with deferring surgical intervention including poor bone and ligament healing, pes planus deformation, and a high likelihood of developing arthritis in the foot. She will be unable to participate for the remainder of the soccer season, but should be able to play next season.
INSTRUCTIONS
We will see the patient on Monday, for surgery. |
D2N061 | aci | [doctor] hi virginia how're you today
[patient] i'm good thanks how are you
[doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened
[patient] i was playing basketball and jerry ran into me and the inside of my knee hurts
[doctor] okay did you fall to the ground or did you just kinda plant and he pushed and you went one way and your knee did n't
[patient] i did fall to the ground
[doctor] you did fall to the ground okay and did you land on the kneecap i mean did it hurt a lot were you able to get up and continue on
[patient] i landed on my side i was not able to continue on
[doctor] okay so you get off the off the court is jerry a good player you just got ta ask that question
[patient] not really
[doctor] no
[patient] he does n't have much game
[doctor] okay okay well you know i love basketball i'm a little short for the game but i absolutely love to watch basketball so it's really cool that you're out there playing it so tell me about a little bit about where it hurts
[patient] on the inside
[doctor] on the inside of it okay and after the injury did they do anything special for you or you know did you get ice on it right away or try anything
[patient] i had ice and an ace wrap
[doctor] you had ice and what
[patient] an ace wrap
[doctor] and an ace wrap okay now how many days ago was this exactly
[patient] seven
[doctor] seven days ago okay yeah your right knee still looks a little swollen for seven days ago so i'm gon na go ahead and now i also see that you're diabetic and that you take five hundred milligrams of metformin twice a day are you still you're still on that medication is that correct
[patient] correct
[doctor] and do you check your blood sugars every morning at home
[patient] every morning
[doctor] okay great and since this i'm the reason i'm asking all these questions i'm a little concerned about the inactivity with your your knee pain and you know how diabetes you need to be very you know active and and taking your medicine to keep that under control so you know may wan na continue to follow up with your pcp for that diabetes as we go through here and just watch your blood sugars extra as we go through that now i'm gon na go ahead and examine your your right knee and when i push on the outside does that hurt at all
[patient] no
[doctor] okay and when i push on this inside where it's a little swollen does that hurt
[patient] yes
[doctor] yeah okay i'm just gon na ask a question did you hear or feel a pop in your knee when you were doing this
[patient] i did not no
[doctor] you did not okay okay what are you doing for the pain today
[patient] some exercises ice and mobic
[doctor] okay okay so i'm gon na continue all of my exam when i go ahead and pull on your knee the first thing i'm looking at is i do see some ecchymosis and swelling on the inside of that right knee and when i push around that knee i can see that there is fluid in the knee a little bit of fluid in the knee we call that effusion so i can appreciate some of that effusion and that could be either fluid or blood at this point from the injury that you had now you do have pain with palpation on the medial aspect of that right knee and that's that's concerning for me when i'm gon na just i just wan na move your knee a little bit it does n't look like when i extend it and flex it that you have a full range of motion does it hurt a lot when i moved it back a little more than normal
[patient] yes it hurts
[doctor] okay okay yeah so you do have some decreased range of motion in that right knee now i'm just gon na sit here and and lay you back and i'm gon na pull on your knee and twist your knee a little bit okay you currently there is a negative varus and valgus stress test that's really important so here's what i'm thinking for that right knee i think you have may have a medial collateral ligament strain from you know maybe the twisting motion be right before you fell to the ground i want you to continue to use an ace wrap i'm gon na give you a right knee brace we're gon na wear that for a few days and then i'm gon na send you to physical therapy so we can continue strengthening the muscles around the right knee now that x-ray as far as the x-ray results that x-ray that i did it this morning in the office the the bony alignment's in good position i do n't see any evidence of any fractures i do notice the the effusion around the right knee just a small amount of fluid but we're just gon na continue to watch that i'm gon na give you a prescription i'd like you to stop taking any of the nonsteroidals that you're taking the motrin or advil whichever one of those and i'm gon na give you meloxicam fifteen milligrams and i want you to take that daily for the pain and swelling i want you to just continue exercising with the the braces and everything on so if you can you can get out and do some light walking that'll be good and then again for your diabetes like i said just continue to watch those blood sugars daily and if you start to see any significant increase in them because of your loss of activity just reach out to your primary care physician now do you have any questions for me
[patient] when can i play basketball again
[doctor] yeah that's a great question i'm gon na ask well my first off i want to see you back here in in seven days you know in a week i want you to make an appointment we're gon na relook at it we're gon na determine if that swelling got any worse and if we need to go on to potentially ordering like a cat scan or an mri of that knee to look and see if there was any significant damage to the ligament so that's for for sure for seven days you're not gon na be playing basketball now are you in a ligue or is that just you get like pick up basketball
[patient] i just played the wife with fun
[doctor] okay okay good that's a great activity like i said i wish i could play now i i also know your your family do n't they own that sports store down right off a main street that sells a lot of sporting equipment
[patient] yeah they do
[doctor] okay i you know i'm i'm just thinking you know i need to get some new shoes for some of it my activities i love the i wish i could play basketball but i do a lot of bike riding so i'm always looking for anything that's gon na help me on the bike do you does your family have supplies like that
[patient] we do let me know and i can get you the hook up
[doctor] okay great great so i'll i i will let you know i'll just get on and take a look first but i'm gon na go ahead and get get you discharged i'll have my assistant come in we will get you discharged and like i said we will make an appointment for seven days and we will go from there any questions
[patient] i think you've answered them all thank you
[doctor] okay great | CHIEF COMPLAINT
Right knee pain.
HISTORY OF PRESENT ILLNESS
Virginia Phillips is a pleasant 53-year-old female who presents to the clinic today for the evaluation of right knee pain. The onset of her pain began 7 days ago, when she was playing basketball and another player ran into her. She states that she fell to the ground and landed on her side. She denies hearing or feeling a pop at the time of the injury. The patient localizes her pain to the medial aspect of her knee. She used ice and an ACE wrap right after the injury. Today, she notes that she has been doing exercises, ice, and Mobic for pain control.
MEDICAL HISTORY
The patient reports she is a diabetic who takes her blood sugar every morning.
SOCIAL HISTORY
Patient reports that she plays basketball at the Y for fun.
MEDICATIONS
Patient reports that she takes metformin 500 mg twice a day.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right knee pain.
PHYSICAL EXAM
MSK: Examination of the right knee: No pain to palpation of the lateral aspect of the right knee. Pain with palpation on the medial aspect of the knee. Ecchymosis and swelling on the medial aspect of the knee. Effusion is appreciated. Decreased ROM. Negative varus and valgus stress test.
RESULTS
X-rays of the right knee taken in office today reveal the bony alignment in good position. There is no evidence of any fractures. There is effusion present.
ASSESSMENT
Right knee pain, possible medial collateral 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 prescribed the patient meloxicam 15 mg once a day to treat the pain and swelling. She was advised to stop taking any anti-inflammatory such as Motrin or Advil. I have also recommended that the patient attend formal physical therapy to strengthen her right knee. I have also advised her to continue to use the ACE wrap and wear a right knee brace for a few days. She should continue light walking with her brace on. The patient was advised to stop basketball until she follows up in 7 days.
Regarding her diabetes, she should continue to monitor her blood sugars daily. She should reach out to her primary care physician if she sees an increase in her blood sugars due to loss of activity.
INSTRUCTIONS
The patient will follow up with me in 7 days to check on her progress. If her swelling has not improved, we will consider obtaining a CT or MRI of the right knee to evaluate for a possible medial collateral ligament strain. |
D2N062 | aci | [doctor] okay raymond it looks like you've been having some difficulty swallowing over for a period of time could you tell me like what's going on
[patient] well i've been better for the last several weeks i've been noticing that it's been hard for me to swallow certain foods and i also have pain when i swallow down in my chest
[doctor] okay and when does it does it happen every time you eat
[patient] it hurts not every time it hurts when i when i swallow most foods but it's really just the bigger pieces of food that seem like they're getting stuck
[doctor] okay and what do you mean by bigger pieces of food like what's your diet like
[patient] well things have been stressed over the last couple of months so lacks a moving from the west coast of east coast so i've been drinking more eating things like pizza burgers i know it's not good but you know it's been pretty busy
[doctor] wow that sounds kinda stressful like what are you moving for
[patient] well i'm stressed because what i'm moving because you know i i do n't like the west goes so i i decided to move but you know it's just stressful
[doctor] uh uh
[patient] because i do n't know how my dog is gon na handle the travel but i do n't wan na put them into the carbo portion of the plane we fly out of her really bad stories of dogs got in the wreck
[doctor] okay so are you thinking of driving
[patient] i i think so i think i'm i think i'm gon na end up driving but that's still a a long trip
[doctor] yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms
[patient] no i wish unfortunately i've gained some weight
[doctor] okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea
[patient] sometime my belly hurts up here
[doctor] okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool
[patient] not that i noticed
[doctor] okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt
[patient] no i did that hurts
[doctor] okay pain to palpation of epigastric area how about now
[patient] no
[doctor] okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for your i reviewed the results of your barium swallow and it showed that you have two areas of mild narrowing in the mid and lower portions of your esophagus that can be found in patients experiencing something called esophagitis so for your primary primary problem you have acute esophagitis i wan na go ahead and prescribe protonix it's forty milligrams you're gon na take that once a day you should take it the first thing in the morning i also wan na prescribe to you something called carafate you take one gram four times a day for one month that's just gon na help kind of coat your the in the lining of your esophagus and like your stomach so that you're again like not producing a whole lot of acid like your your pretty much your the acid in your stomach is getting where it does n't need to be and it's a bit too strong so we're gon na give your body time to do a reset i wan na schedule you for an upper endoscopy just to be sure we are n't missing anything else i encourage you to change your diet and decrease alcohol and caffeine i know that's gon na be pretty hard with the move but you know once especially once you're settled in it's gon na be very important for us to to like focus on like getting well and eating healthy so that you know like you can you can move about your day as best as you can and and enjoy your move i want you to consider like eating slowly and chewing your food more thoroughly so that you do n't have to deal with those big pieces i also want you to avoid citrus foods fruits and spicy foods until your symptoms have improved i wan na see you again next week for that endoscopy i know there was a lot of information do you have any questions
[patient] no i think that's all good
[doctor] okay alright thank you so much for coming in | CHIEF COMPLAINT
Difficulty swallowing.
HISTORY OF PRESENT ILLNESS
Raymond Taylor is a pleasant 67-year-old male who presents to the clinic today for difficulty swallowing. The patient notes that the pain has been occurring for the last several weeks. The pain radiates to his chest when he swallows. He notes that he does not have pain every time he eats but mostly when he has big pieces of food as they seem to get stuck. Mr. Taylor notes that it has been stressful for him the past couple of months as they moved from the West Coast to the East Coast, so he has been drinking more, and having pizza, and burgers more. He denies any weight loss, but endorses weight gain. The patient states that he has epigastric pain, but denies dark, tarry stools.
REVIEW OF SYSTEMS
Constitutional: Reports weight gain.
HENT: Reports dysphagia.
Gastrointestinal: Reports epigastric pain. Denies dark, tarry stools.
Neurological: Positive stress.
VITALS
BP: 133/70.
Heart rate looks good.
Temperature is within normal limits.
SpO2: 100%.
Respiratory rate: 19.
PHYSICAL EXAM
EYES: Equal and reactive to light.
NECK: No adenopathy, thyromegaly.
RESPIRATORY: Normal respiratory effort no respiratory distress
GI/GU: Non-distended Active bowel sounds. Pain to palpation of epigastric area. Negative McMurphy's Sign. No peritoneal signs. No rebound.
SKIN: No rash, no lesion, no bruising.
MSK: Examination of the mouth reveals no obvious ulcers or evidence of thrush present. Tonsils are midline of the neck.
RESULTS
The barium swallow study revealed two areas of mild narrowing in the mid and lower portions of your esophagus.
ASSESSMENT
Acute esophagitis.
PLAN
After reviewing the patient's examination and barium swallow findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have prescribed the patient Protonix 40 mg first thing in the morning to treat his acute esophagitis. I have also prescribed the patient Carafate 1 gram 4 times daily for 1 month to help coat the lining of his esophagus and stomach. I recommended a upper endoscopy for further evaluation. I have also advised him to change his diet, decrease alcohol, and caffeine. I have also advised him to avoid citrus foods, fruits, and spicy foods until his symptoms have improved. We discussed that he should eat slowly and chew his food thoroughly to avoid big pieces of food. All questions were answered.
INSTRUCTIONS
The patient will follow up with me in 1 week for his endoscopy. |
D2N063 | aci | [doctor] so gloria is a 46 -year-old female today with past medical history of diabetes and back pain and today here for shortness of breath with chf and copd also so gloria tell me what's going on
[patient] i i i'm having a lot of trouble sleeping
[doctor] okay and and how long has this been going on for
[patient] really just for about the past two weeks i i just ca n't ca n't get comfortable you know when i when i lay down in bed i just ca n't ca n't fall
[doctor] is it because you're having you ca n't sleep or you're having shortness of breath or difficulty breathing or what's going on with that
[patient] yeah i i feel like i'm just i'm just choking a few minutes after i i lay down to sleep i just ca n't catch my breath
[doctor] okay and are you and how has your pulse ox been your oxygen level been at home i know you your oxygen level here is like ninety two right now in the office which is a little bit on the low side how is how has that been at home
[patient] i can breathe fine
[doctor] just when you lay down you get short of breath okay and is it worse when you have you noticed any shortness of breath during the day when you exert yourself when you climb stairs or do other stuff
[patient] i do n't i do n't do any of that usually i just i i sit on the couch and watch my shows
[doctor] okay fair enough and how about have you noticed any weight gain or swelling in your legs or calves or anything like that
[patient] yeah i i ca n't see my ankles anymore and and yeah i i do n't know what's going on with the scale i think the numbers are off because you know suddenly i gained about ten pounds
[doctor] wow okay alright and are you taking i know you were supposed to be taking lasix and we had you on you know diet control to to prevent to limit your salt intake how is that going
[patient] i i i do n't know how much salt is in freedoes but you know i i i'm really enjoying those in last weekend we got this really big party and yeah which color is that lasix pill
[doctor] yeah it's it's the white one the round one so it sounds like you're not maybe not taking it as regularly as you should
[patient] no sir i i do n't think i am
[doctor] okay alright and are you having any chest pain or tightness in your chest or anything like that or not really
[patient] no not really
[doctor] okay
[patient] just just when i ca n't breathe good at night you know
[doctor] okay got it
[patient] yeah
[doctor] so i'll examine you in a second so it's been a couple of weeks are you coughing up anything any fevers with this at all
[patient] no no fever kinda feel like i'm just bringing a whole bunch of yuck up once in a while though especially first thing in the morning
[doctor] okay alright and how have your blood sugars been doing this time i know you're taking the metformin are you checking your accu-cheks how has that been going
[patient] i i'm sorry what's an accu-chek
[doctor] for your blood sugar check are you checking that or not really
[patient] i i i did it a couple of weeks ago
[doctor] okay
[patient] and it was about it i i think about two thirty it was okay
[doctor] okay so your hemoglobin a1c last time was seven . five and we had talked about you know trying to improve your diet we had talked about you know we wan na avoid going to insulin but it sounds like it's been a challenge to kinda control the diet and also your blood sugars have been running a little bit high
[patient] yeah
[doctor] okay alright
[patient] yeah it's it's been a challenge
[doctor] alright and any nausea vomiting or diarrhea or anything like that are you peeing a whole lot or anything like that no
[patient] yeah i'm feeling like crazy
[doctor] okay alright
[patient] ca n't figure out why because i'm not drinking very much
[doctor] alright and how is your back then has that been okay i know you're sitting you said you're sitting on the couch a lot watching tv but
[patient] yeah
[doctor] besides that anything else
[patient] yeah you know it it just it just really hurts so you know and so that's why i sit on the couch so much
[doctor] okay alright no weakness or numbness in your legs right now
[patient] no
[doctor] okay
[patient] no
[doctor] so let me examine you now gloria i'm gon na go ahead and do an exam and let's pretend i did my exam i'm just gon na verbalize some of my findings just so i can record this and put it into my my into my chart so neck exam you do have a little bit of swelling in your neck little bit of jvd no bruits your lung exam you have some crackles in both bases and some rales that i can hear and there are a little bit of intermittent wheezing as well on your heart exam you have a two over six systolic ejection murmur you've had that in the past otherwise regular rate and rhythm it does n't feel a regular your belly exam your belly's slightly distended there's no tenderness or guarding or anything like that so that does n't that looks pretty good on your leg exam you do have some one plus pitting edema or actually almost one and a half plus pitting edema in your both of your ankles no calf tenderness negative homans sign that means no blood clots otherwise neurologic exam is normal the rest of your exam is normal so what does this all mean so let me explain that so for the first problem the shortness of breath you know i think you have an exacerbation of your congestive heart failure what i'd like to do is increase your dose of lasix from twenty milligrams to sixty milligrams for the next four days i'm gon na have you check your weights everyday and also i'm gon na go ahead and have you use your albuterol and atrovent we had given you some inhalers in the past i can give you another refill if you need to help with that some of the breathing that you're having the shortness of breath so i'd like to get some of this fluid off you have you check your weights daily we'll have you increase your dose of lasix we'll have you use a breathing treatments and see if that helps your shortness of breath i'd like to have you come back in about couple days actually i wan na see how you're doing and if it does n't get better we may have to increase the dose or send you to the hospital okay
[patient] i do n't want to go to the hospital doctor
[doctor] yeah so let's try to let's try to use the lasix and let's try to let's try to you know use the breathing treatments and and do that for the second problem the diabetes that we just talked about i like to go ahead and order another blood test another hemoglobin a1c i think we need to your blood sugars have been running a little bit high in the past and we've had a hard time but it's been a while since we checked your last one so i wan na check another one today to see where we are and when we have you come back in a couple days we should have the results back we can then adjust your metformin or we may have to adjust some of the you know add a different medication at that point but but right now i'm gon na order some blood tests we'll have you come back in a couple of days and then we can reassess at that point okay
[patient] so i had a piece of cake before i came in here is that gon na affect the the lab work
[doctor] yeah we'll probably do a fasting blood sugar we'll we'll order the hemoglobin a1c that should n't be actually matter because that checks long term but if we need your blood sugar may be elevated today i i would n't be surprised alright and i forgot to examine your back by the way so on your back exam you do have some tenderness in the paraspinal areas of your back in the in the lower back mostly no midline tenderness you have good reflexes so i think this is all muscular pain right now for your back pain i'm gon na go ahead and put you on some naprosyn and some flexeril which is a muscle relaxer i'm gon na give you some exercises you can do to help you get off the couch it'll also help your blood sugar and why do n't we have you if that does n't work the the pain medicine and the physical we can start physical therapy and see if that helps okay
[patient] okay
[doctor] any questions about that
[patient] i do n't think so which color pills
[doctor] i think it's a white pill and it's round
[patient] okay
[doctor] about this big
[patient] alright sounds good
[doctor] anything else gloria
[patient] no that's it
[doctor] alright thanks for coming in today | CHIEF COMPLAINT
Dyspnea.
MEDICAL HISTORY
Patient reports history of diabetes, back pain, congestive heart failure, and chronic obstructive pulmonary disease.
SOCIAL HISTORY
Patient reports living a sedentary lifestyle.
MEDICATIONS
Patient reports she is not consistent with taking Lasix and metformin.
REVIEW OF SYSTEMS
Constitutional: Reports 10 pound weight gain. Denies fever.
Cardiovascular: Denies chest pain or tightness.
Respiratory: Reports orthopnea and productive cough. Denies dyspnea on exertion.
Gastrointestinal: Denies nausea, vomiting, or diarrhea.
Genitourinary: Reports polyuria.
Musculoskeletal: Reports back pain and lower extremity edema.
Neurological: Denies lower extremity weakness or numbness.
VITALS
Oxygen saturation: 92%
PHYSICAL EXAM
Neck
- General Examination: Slight swelling. Mild JVD. No bruits.
Respiratory
- Auscultation of Lungs: Mild rales heard at the base bilaterally and slight intermittent wheezing.
Cardiovascular
- Auscultation of Heart: 2 out of 6 systolic ejection murmur, otherwise regular rate and rhythm.
Gastrointestinal
- Examination of Abdomen: Slightly distended. No tenderness or guarding.
Musculoskeletal
- Examination: 1.5+ pitting edema in the ankles bilaterally. No calf tenderness. Negative Homan's sign. Slight tenderness in the paraspinal area, mostly in the lower back. No midline tenderness. Good reflexes.
RESULTS
Hemoglobin A1c: 7.5
ASSESSMENT AND PLAN
1. Shortness of breath.
- Medical Reasoning: I believe this is an exacerbation of her congestive heart failure.
- Patient Education and Counseling: I advised the patient to monitor her weight daily.
- Medical Treatment: She will increase her dose of Lasix from 20 mg to 60 mg for the next 4 days. She should also use her albuterol and Atrovent inhalers as needed. If her symptoms don't improve in the next couple of days, we will either increase her doses or have her go to the hospital.
2. Diabetes type 2.
- Medical Reasoning: Her recent blood glucose levels have been elevated.
- Patient Education and Counseling: We discussed the possibility of needing to add another medication to her regimen.
- Medical Treatment: We are going to order a repeat hemoglobin A1c and adjust her dose of metformin accordingly.
3. Back pain.
- Medical Reasoning: This appears to be all muscular pain.
- Patient Education and Counseling: We discussed exercises she can do to help her pain and that ff this doesn't help we can consider physical therapy.
- Medical Treatment: Prescriptions provided for Naprosyn and Flexeril.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
We will have her follow up in a couple of days. |
D2N064 | aci | [doctor] hey matthew how're you doing
[patient] hey doc i'm doing pretty good how are you
[doctor] i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that
[patient] yeah i did my wife and i were on a walk yesterday and i was just talking to her and and stepped off the curb and landed on it wrong it's kind of embarrassing but yeah it's been killing me for a couple days now
[doctor] okay now when you fell did you feel or hear a pop or anything like that
[patient] i would n't say i really heard a pop it was just kind of really kind of felt extended and stretched and it it's just been really bothering me ever since kind of on the outside of it
[doctor] okay and then were you able to walk on it after the incident
[patient] i was able to get back to the house because i did n't wan na you know make my wife carry me but it was it was painful
[doctor] okay and then have you done any or had any injuries to that ankle before
[patient] nothing substantial that i would say in the past
[doctor] okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less
[patient] i have taken some ibuprofen and then i just tried to elevate it and ice it a little bit and keep my weight off of it
[doctor] okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me
[patient] i would say it's about an eight
[doctor] okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then
[patient] maybe a seven it it's a little
[doctor] okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there
[patient] we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time
[doctor] yeah i
[patient] no i have n't been there yet
[doctor] yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay
[patient] awesome
[doctor] so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up
[patient] no i think that sounds like a plan
[doctor] okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks
[patient] awesome thanks document
[doctor] alright thanks bye-bye | CHIEF COMPLAINT
Left ankle pain.
HISTORY OF PRESENT ILLNESS
Matthew Murphy is a pleasant 20-year-old male who presents to the clinic today for the evaluation of left ankle pain. The onset of his pain began 2 days ago, when he stepped off of a curb and landed on his left ankle wrong. He denies hearing a pop at the time of the injury, however, he describes his ankle as feeling extended and stretched. He was able to ambulate back to his house after the incident but with pain. He denies any previous injuries to his left ankle. His pain is localized to the lateral aspect of his left ankle and can be rated at 8 out of 10 without medication. When taking ibuprofen his pain level is 7 out of 10. He states he has also iced and elevated his ankle.
SOCIAL HISTORY
Patient reports that he has been working from home since the start of COVID-19 and enjoys taking lots of walks.
MEDICATIONS
Patient reports taking ibuprofen.
REVIEW OF SYSTEMS
Musculoskeletal: Patient reports left ankle pain.
VITALS
Vitals are slightly elevated due to pain level but are otherwise stable.
PHYSICAL EXAM
NEURO: Normal strength and sensation bilaterally.
MSK: Examination of the left ankle: Ecchymosis noted over the lateral malleolus. Edema is present. Tenderness to palpation laterally. No joint laxity appreciated. No bony tenderness to palpation of the foot. Capillary refill is brisk at less than 3 seconds bilaterally. Strong dorsalis pedis pulses bilaterally.
RESULTS
These reveal no fracture or bony abnormalities.
ASSESSMENT
Left ankle sprain of the lateral ligament complex.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his symptoms are consistent with an ankle sprain of the lateral ligament complex. The nature of the diagnosis and treatment options were discussed. At this time he will continue to follow the RICE protocol. He will continue to take NSAIDs as needed for pain and swelling. He will also be placed into an Aircast for ankle stabilization and will be provided crutches in order to remain non-weight-bearing. We discussed that it may be a few days before he feels able to tolerate walking. I also advised him that his symptoms will likely start to improve significantly over the next 4 to 6 days.
INSTRUCTIONS
The patient will follow up with me in 2 weeks to assess his progress, sooner if needed. |
D2N065 | aci | [doctor] hey anna good to see you today so i'm looking here in my notes says you have you're coming in today for some right ankle pain after a fall so can you tell me what happened how did you fall
[patient] yeah so i was taking out the trash last night and i ended up slipping on a patch of ice like and then when i fell i heard this pop and it just hurts
[doctor] okay so have you been able to walk on it at all or is it you know
[patient] at first no like my friend who was visiting thankfully had to help me get into the house and i you know and now i'm able to put like a little bit of weight on it but i'm i i'm still limping
[doctor] okay well you know that's not good we'll we'll hopefully we can get you fixed up here so how much how much pain have you been in on a scale of one to ten with ten being the worst pain you ever felt
[patient] it's it's more like so when i first fell it was pretty bad but now it's it's at like a six you know like it's uncomfortable
[doctor] okay and how would you describe that pain is it a constant pain or is it only when you move the ankle
[patient] it's it's constant it's like a throbbing pain you know and like when i touch it it feels kinda warm
[doctor] okay alright yeah but yeah i can feel it here so it does feel a little bit warm so i said you've been in a little bit of pain so have you taken anything for it
[patient] well like last night i iced it and i kept it elevated you know i also took some ibuprofen last night and this morning
[doctor] alright has the ibuprofen helped at all
[patient] not really
[doctor] okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before
[patient] so you know in high school i used to play a lot of soccer but and and like i had other injuries but i've never injured like this particular ankle before but because i used to play like all the time i knew what i was supposed to do but this is i also knew that it was it was time to come in
[doctor] okay yeah yeah definitely if you if you ca n't walk on it we definitely good thing that you came in today and we were able to see you so have you experienced any numbness in your foot at all
[patient] no no numbness and i do n't think i've had like any tingling or anything like that
[doctor] okay that that's good yeah it sounds like you have sensation there so yeah that that's really good so let me do a quick physical exam on you so i reviewed your vitals your blood pressure was one twenty over eighty which is good your heart rate your spo2 was ninety eight percent which is good that means you're you're getting all of your oxygen and so let me go ahead and look at your ankle real quick so when i press here does that hurt
[patient] yeah
[doctor] alright what about here
[patient] yeah
[doctor] okay so looking at your ankle and your right ankle exam on the skin there is ecchymosis so you have that bruising which you can see of the lateral
[patient] malleolus
[doctor] malleolus associated with swelling there is tenderness to palpation of the anterior laterally in the soft tissue there is no laxity on the anterior drawer and inversion stress there is no bony tenderness on palpation of the foot on your neurovascular exam of your right foot there your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch alright so we did get an x-ray of your ankle before you came in and luckily it's there is no fractures no bony abnormalities which is really good so let me talk a little bit about my assessment and plan for you so for your right ankle pain your symptoms your symptoms are consistent with a right ankle sprain have you sprained your ankle before most times people do the athletics play soccer it happens every so often but have you done that before
[patient] no i do n't think so
[doctor] okay well you're one of the lucky ones some of my my patients that play sports they sprain their ankle seems like every other week so good for you so for that that that ankle sprain i just want to keep i want you to keep your leg elevated when you're seated and i want you to continue to ice it you can ice it let's say five times a day for twenty minutes at a time just to help that swelling go down i'm gon na give you an air cast to help you stabilize the ankle so keep it from moving and then i'll give you crutches and so i want you to stay off that leg for about one to two days and then you can start walking on it as tolerated tolerated so how does that sound
[patient] it's alright
[doctor] alright so do you have any questions for me
[patient] yeah like how long do you think it's gon na take for me to heal
[doctor] i mean it should take a a couple of days i mean i think in a day or two you will be able to walk on it but still think it will be sore for the next couple of weeks you know your ankle sprain seems to be not the worst but it's kinda you know medium grade ankle sprain so as i would say about two to three weeks you should be back to normal you will see some of that bruising go away
[patient] yeah okay can i get a doctor's note
[doctor] no because you need to go back to work because you work on the computer not running so
[patient] fine
[doctor] yeah you ca n't get a doctor's note so if you if i write a note i'm gon na tell your boss that you have to go to work
[patient] okay thanks
[doctor] so i i would n't do that but yeah but otherwise if if if you continue to have pain after this week if you feel like it's not getting better please feel free to contact the office and we can get you back in and possibly do an mri if we you know need to
[patient] okay
[doctor] alright
[patient] alright
[doctor] anything else
[patient] no that's it
[doctor] alright thanks | CHIEF COMPLAINT
Right ankle pain.
HISTORY OF PRESENT ILLNESS
Anna Diaz is a pleasant 31-year-old female who presents to the clinic today for the evaluation of right ankle pain. The onset of her pain began when she slipped on a patch of ice while taking out the trash. She states that she heard a pop at the time of the injury. The patient reports that she was unable to ambulate on her right ankle initially after the injury; however, she is now able to bear some weight on her right ankle, but she is still limping. The patient rates her pain level as a 6 out of 10. Ms. Diaz describes her pain as constant and throbbing. She reports that her right ankle is warm to the touch. She denies any numbness or tingling in her right foot. The patient has been icing and elevating her right ankle while also utilizing ibuprofen last night and this morning, which did not provide her with any relief. The patient states that she used to play a lot of soccer in high school so she notes that she has had other right foot injuries but not like this.
REVIEW OF SYSTEMS
Musculoskeletal: Positive right ankle pain.
Skin: Positive warmth to the right foot.
Neurological: Denies any numbness or tingling.
VITALS
BP: 120/80
SPO2: 98%.
PHYSICAL EXAM
CV: Capillary refill is less than 3 seconds. Strong dorsalis pedis pulse.
NEURO: Normal sensation. Sensation is intact to light touch distally.
MSK: Examination of the right ankle reveals ecchymosis over the lateral malleolus associated with swelling. Tenderness to palpation anterolaterally in the soft tissue. No laxity on anterior drawer or inversion stress. No bony tenderness on palpation of the foot.
RESULTS
X-ray of the right ankle taken in office today reveals no fracture or bony abnormalities.
ASSESSMENT
Right ankle sprain.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her symptoms are consistent with a right ankle sprain. I have recommended that we treat the patient conservatively. I have advised her to keep her right leg elevated when she is seated. I have also advised her to ice her right ankle 5 times per day for 20 minutes at a time to help with the swelling. I have also recommended that the patient be placed in an Aircast to stabilize the ankle. She will remain non-weight-bearing for 1 to 2 days, we provided her with crutches today, and then she can begin weight-bearing as tolerated.
INSTRUCTIONS
If her pain does not improve over the next week, she will contact the office and we will obtain an MRI.
|
D2N066 | aci | [doctor] hey gabriel i'm doctor scott good to see you today i know you've heard about dax is it okay if i tell dax a little bit about you
[patient] sure
[doctor] okay so gabriel is a 43 -year-old male today here for back pain evaluation and also has a past medical history of diabetes high blood pressure and high cholesterol so gabriel tell me what's going on with your back
[patient] well i was working in the yard and you know bent over to pick something up and i got this pain and you know across the lower part of my back and then it went down my left leg and you know it's been going on for about four days and just does n't seem to be getting any better
[doctor] okay are you a big gardener or this is something that you just started working in the yard
[patient] yeah i know my wife held a gun to my head make me go out there work in the yard and carry some stuff around it's not my not my first choice but
[doctor] sure sure
[patient] but that day i i lost the i lost the argument
[doctor] yeah yeah that happens to all of this so when this back pain happened so it was basically you were lifting you were bending down to lift something up and you had the sharp pain going down your right leg you said
[patient] left leg
[doctor] left leg okay got it sorry and any weakness or numbness in your legs or just the pain mostly
[patient] in in certain positions i get some tingling but no mostly just pain
[doctor] okay and any loss of bowel or bladder function at all or anything like that
[patient] no
[doctor] okay and have you had any back surgeries or back problems in the past or this is kind of the first time
[patient] no surgeries you know i've i've had back pain occasionally over the years
[doctor] okay have you had any any have you tried anything for pain for this have you tried any any medications at all
[patient] i've had ibuprofen it it helped some
[doctor] okay got it alright well i'll i'll examine you in a second but before we do that let's talk about some of the other conditions that we're kinda following you for i'm looking at your problem list now and you've got a history of diabetes and you're on metformin five hundred milligram twice a day and your how are you doing with your blood sugars and your and your diet and exercise
[patient] yeah i i check my sugar two or three times a week most of the time it's in that one twenty to one forty range
[doctor] okay
[patient] yeah i take my medicine okay my diet is alright you know i could be fifteen pounds lighter that would be alright but
[doctor] sure
[patient] i i i think the sugar has been okay
[doctor] okay we checked your hemoglobin a1c last time i'm looking at your records in epic and it showed that it was you know seven . one so it's it's it's good but it could be better any you know we talked about it controlling your diet or improving your diet and trying to have a balanced meal and not eating some of these sweets and high sugar items how is that going i know you had talked about your wife being a great cook and making cookies and that's hard to stay away from obviously how are things going with that
[patient] yeah she still makes cookies and i still eat them but you know we are trying to trying to do better trying to stay away from more of those carbs and focus on you know less carby less sweet stuff
[doctor] okay alright yeah that's always a struggle i certainly understand but you know really important with your diabetes just to prevent some of the complications like kidney failure and eye problems and just keep your sugar under balance so i'll order another hemoglobin a1c today we'll check that again today and and you know just reemphasizing the controlling your diet and exercise is super important and then we'll have those results back we'll we'll see if we need to make any modifications okay
[patient] okay
[doctor] for your high blood pressure your blood pressure in the clinic looks pretty good it's about one twenty over seventy right now we have you on norvasc five milligrams once a day how are things going with that are you are you checking that periodically or any issues with that at all
[patient] yeah i guess i check it maybe once a week or two or three times a month and it it the vast majority of the time when i check it it's good usually either that one twenty to one thirty over seventy to eighty range i i think the blood pressure's okay
[doctor] okay
[patient] i have n't had any real problems there i i have had some some swelling in my ankles though
[doctor] okay is that new or is that been going on for a while
[patient] well it it started maybe i do n't know a month or two after i started the norvasc
[doctor] okay
[patient] and i was just wondering if the two might be related
[doctor] yeah i mean certainly it could be it is you know sometimes that medication can cause that so i'll i'll examine you in a second and see if we need to make any modifications okay
[patient] okay
[doctor] alright so and your anything else bothering you today
[patient] no i'm we're doing okay i think
[doctor] so let me examine you for a second i'm gon na go ahead and gabriel i'm gon na do my magic exam now let's pretend i i'm just gon na verbalize some of my findings as i do my exam and so
[patient] these are like my video visit exams
[doctor] exactly so your neck exam has no jvd there is no bruits that i can hear your lung exam no rales no wheezing on your heart exam you do have a two over six systolic ejection murmur you had that in the past so i'm not too worried about that otherwise regular rate and rhythm on your heart exam on your on your on your belly exam is nice and soft on your back exam you do have some tenderness on the left paraspinal area right where i'm pressing right there your straight leg raise test is negative your reflexes are normal you have some just some tenderness in the lower back in the paraspinal area of your back when i palpate there otherwise your neurological exam is normal on your extremity exam you do have this one plus nonpitting edema of your lower extremities which is a little bit of swelling in your ankles no calf tenderness negative homans sign no signs of blood clot that's what that means so let me just review what you know explain what all this means so the back pain the first problem that you're here today for i think this is more of a muscular sprain i'm gon na recommend we start you on some anti-inflammatory naprosyn five hundred five hundred milligrams twice a day and flexeril ten milligrams twice a day as well i'm gon na refer you to for for physical therapy to help strengthen some of the muscles in your lower back i do n't think you need an x-ray at this stage why do n't we start with physical therapy and the muscle relaxers and the pain medicines if it does n't get better then we can get an x-ray but right now i would start with that if that's okay with you any questions about that
[patient] no
[doctor] okay for the diabetes the the second problem that we talked about today i'm gon na order another hemoglobin a1c continue the metformin five hundred milligrams twice a day why do n't we have you come back in about two weeks and we should have some of the results back and we can discuss if we need to make any modifications for that but right now we will continue the course and we will go from there okay for the high blood pressure you do have this one plus edema in your legs i'm gon na go ahead and order some blood work today i'm gon na go ahead and stop the norvasc and we'll put you on some hydrochlorothiazide ten milligrams once a day and if that does n't get if the swelling does n't go away i'm gon na do some more testing for right now let's get some sort off with some cbc and a bmp i'm gon na check your kidney function i'm gon na get another ekg and also i'm gon na get a chest x-ray and we'll go from there but hopefully this will go away once we stop this medication since it started around that time okay okay and i think that's it anything else we forgot about do you need refills for anything
[patient] no i i think i'm okay you gave me a year's worth of refills last time we were together
[doctor] okay sounds great alright thanks gabriel good seeing you again
[patient] good to see you thanks | CHIEF COMPLAINT
Back pain evaluation.
MEDICAL HISTORY
The patient has a history of diabetes, hypertension, and high cholesterol.
SURGICAL HISTORY
He denies previous back surgeries.
MEDICATIONS
The patient currently utilizes metformin 500 mg twice daily and Norvasc.
REVIEW OF SYSTEMS
Cardiovascular: Reports ankle swelling.
Musculoskeletal: Reports lower back pain.
Neurological: Reports tingling in left leg. Denies weakness or numbness in legs, or loss of bowl or bladder function.
PHYSICAL EXAM
Neurological
- Orientation: Alert and oriented x3. Cranial nerves grossly intact. Normal gait.
Neck
- General Examination: No JVD. No bruits.
Respiratory
- Auscultation of Lungs: No wheezes, rales.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. 2/6 systolic ejection murmur. Otherwise, regular rate and rhythm.
Musculoskeletal
- Examination: Tenderness on the left paraspinal area. Straight leg raise test is negative. Reflexes are normal. 1+ nonpitting edema of lower extremities. No calf tenderness. Negative Homan's sign.
ASSESSMENT AND PLAN
1. Lower back pain.
- Medical Reasoning: I believe this is more of a muscular sprain.
- Patient Education and Counseling: We discussed treatment options today.
- Medical Treatment: I am going to start him on Naprosyn 500 mg twice a day and Flexeril 10 mg twice a day. I will refer him for physical therapy to help strengthen some of the muscles in his lower back.
- Additional Testing: I do not think he needs an x-ray at this stage, however if he does not improve, we will order one for further evaluation.
2. Diabetes.
- Medical Reasoning: His most recent A1c was 7.1 and his blood sugar levels are typically between 120-140.
- Patient Education and Counseling: We discussed treatment options today.
- Medical Treatment: He will continue the metformin 500 mg twice a day.
- Additional Testing: I am going to order another hemoglobin A1c.
3. Hypertension.
- Medical Reasoning: He does have 1+ edema in his legs.
- Patient Education and Counseling: We discussed treatment options today. I explained that his edema is likely caused by the Norvasc.
- Medical Treatment: The patient will discontinue the use of Norvasc and we will start him on hydrochlorothiazide 10 mg once a day.
- Additional Testing: I will order a CBC and BMP. Additionally, I will order a repeat EKG, as well as a chest x-ray.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up in 2 weeks. |
D2N067 | aci | [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 | CHIEF COMPLAINT
Right knee injury.
HISTORY OF PRESENT ILLNESS
Elizabeth Ross is a pleasant 91-year-old female who presents to the clinic today for the evaluation of a right knee injury. The onset of her pain began 2 weeks ago, when she was downhill skiing. She states she ran into a tree and twisted her right knee. At the time of the injury, she also heard a pop in her left knee, however she denies left knee pain. The patient locates her pain to the medial aspect of her right knee. Currently, her pain level is 7 out of 10, however she notes this can reach an 11 out of 10 at times with prolonged ambulation. The patient states that her pain has been slowly increasing over the last few days. She experiences limping with ambulation. The patient states that her pain lasts for as long as she is ambulating. She denies radiating pain. She also reports constant swelling and stiffness in the morning. Her stiffness will resolve with ambulation. The patient has been wearing a brace and using THC cream, which has been helpful. She denies taking any medications for pain, however she has been utilizing THC gummies, which have been beneficial.
The patient has a history of a right knee reconstruction when she was 14 years old. She states that she was a good gymnast at that time. The patient adds that she has had problems with her right knee since that time. She denies any other exercises outside of intense gym and ski events. The patient states that she normally skis 3 times per week.
SURGICAL HISTORY
The patient reports a history of total right knee reconstruction at the age of 14.
MEDICATIONS
She denies needing medications.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right knee pain, swelling, and stiffness. Denies left knee pain.
PHYSICAL EXAM
MSK: Examination of the right knee: Mild effusion. The patient ambulated with an antalgic gait. Pain with dorsiflexion, but not with plantarflexion.
RESULTS
4 views of the right knee were taken. These reveal no evidence of any fractures. There is development of mild arthritis.
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.
|
D2N068 | virtassist | [doctor] hi , brian . how are you ?
[patient] hi , good to see you .
[doctor] it's good to see you too . so , i know the nurse told you a little bit about dax .
[patient] mm-hmm .
[doctor] i'd like to tell dax about you , okay ?
[patient] sure .
[doctor] so , brian is a 58 year old male with a past medical history significant for congestive heart failure and hypertension , who presents today for follow-up of his chronic problems . so , brian , it's been a little while i've seen you .
[patient] mm-hmm .
[doctor] whats , what's going on ?
[patient] i , i just feel out of sorts lately . i do n't know if it's the change in the seasons or if we're just doing a lot of projects around the house and , and some , some construction on our own . i'm just feeling out of it . lack of , uh , energy . i'm just so tired and fatigued , and i feel kinda ... i feel lightheaded every once in a while .
[doctor] okay . all right . um , how long has that been going on for ?
[patient] uh , probably since labor day , so about five weeks or so .
[doctor] okay . and , have you noticed any , like , symptoms of weight gain , like , like swollen legs , or , you know , your belly feels bloated and things like that ?
[patient] i feel , i feel bloated every once in a while .
[doctor] okay . all right . um , and , are you taking your , your medications ?
[patient] uh , yes , i am .
[doctor] okay . and , how about your diet ? are you watching your diet ?
[patient] uh , it's been a little bit of a struggle . we began construction on our kitchen over labor day weekend , and it was ... hard to cook or prepare meals so we ate out a lot, and not always the best food out. it , it , it kind of reeked havoc , uh , so it's been maybe off a little bit .
[doctor] okay . all right . and , how about , you know , other symptoms , like , have you had a fever or chills ?
[patient] no .
[doctor] okay , and any problems breathing ? do you feel short of breath ?
[patient] uh , just when i'm doing doing the projects . again , not even lifting anything really heavy , it's just that if i'm ex- exerting any energy , i , i kinda feel it at that point .
[doctor] okay . do you have any chest pain ?
[patient] slight cramps . that seems to go away after about , maybe about an hour or so after i first feel it .
[doctor] okay , and how about a cough ?
[patient] a , a slight cough , and again , i'm not sure if it's just the change of seasons and i'm getting a cold .
[doctor] mm-hmm . okay . all right . well , you know , for the most part , how , you know , before all of this-
[patient] mm-hmm .
[doctor] . how were you doing with your heart failure ? i know that we've kinda talked about you being able to watch your healthy food intake and that's been kind of a struggle in the past .
[patient] i , i , i've actually been pretty good about that ever since . the , the , the last year , it's been a little chaotic , but i wanted to make sure i stayed on top of that .
[doctor] okay . all right . are you excited for halloween ?
[patient] uh , ca n't wait .
[doctor] okay .
[patient] our home renovations should be complete by then
[doctor] all right , yeah , right .
[patient] yeah .
[doctor] and , so , lastly , for your high blood pressure , how are you doing with that ? have , are , did you buy the blood pressure cuff like i asked ?
[patient] yeah , i , i did , and we do mon- , i , i monitor it regularly . my wife makes sure i stay on top of that , but it's been pretty good .
[doctor] okay . all right . well , i know you did the review of systems sheet when you checked in , and you were endorsing this fatigue-
[patient] mm-hmm .
[doctor] . and a little dizziness and we just talked a lot about a lot of other symptoms .
[patient] mm-hmm .
[doctor] any other symptoms i might be missing ? nausea or vomiting , diarrhea ?
[patient] no .
[doctor] anything like that ?
[patient] no .
[doctor] okay . all right . well , i just want to go ahead and do a quick physical exam .
[patient] mm-hmm .
[doctor] hey , Sarah ? show me the vital signs . so , looking at your vital signs here in the office , everything looks good . you know , your blood pressure and your heart rate and your oxygenation all look really good .
[patient] mm-hmm .
[doctor] so , i'm gon na just take a listen to a few things and check some things out , and i'll let you know what i find , okay ?
[patient] perfect .
[doctor] okay . so , on your physical examination , you know , i do appreciate some jugular venous distention to-
[patient] mm-hmm .
[doctor] to about eight centimeters . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which we've heard in the past . and , on your lung exam , i do appreciate some fine crackles at the bases bilaterally , and your lower extremities have , you know , 1+ pitting edema . so , what does all that mean ? that means i think you're retaining a little bit of fluid .
[patient] mm-hmm .
[doctor] okay ? i wan na just go ahead and look at some of your results , okay ?
[patient] sure .
[doctor] hey , Sarah ? show me the chest x-ray . so , looking here at the results of your chest x-ray , it does look like you have a little bit of fluid in your lungs there , and that can be just from , um , your heart failure , okay ? hey , Sarah ? show me the echocardiogram . so , this is the echocardiogram that we did about four months ago , and this shows that the pumping function of your heart is a little bit reduced at 45 % , and it also shows that leaky valve , the mitral regurgitation that , that you have , okay ? um , so , let me just go over and talk about , a little bit , my assessment and my plan for you .
[patient] mm-hmm .
[doctor] okay ? so , for your first problem , your congestive heart failure , i think you're retaining fluid , and i wan na go ahead and increase your lasix to 80 mg once a day .
[patient] mm-hmm .
[doctor] i want you to weigh yourself every day . i want you to call me if you're gaining more weight .
[patient] mm-hmm .
[doctor] and , i certainly want you to call me if you have any other symptoms of shortness of breath , and i wan na go ahead and order another echocardiogram , okay ?
[patient] sure .
[doctor] hey , Sarah ? order an echocardiogram .
lastly , for your high blood pressure , it looks like you're managing it well at this time , okay ? so , i wan na go ahead and continue with the lisinopril 20 mg a day . i want you to continue to record your blood pressures at home , and report them to me in the patient portal if you see they're getting elevated , okay ?
[patient] mm-hmm .
[doctor] does that sound like a plan ?
[patient] that sounds fine .
[doctor] okay . um , i'm gon na be in touch with you after we get your test results , and we'll go from there , okay ?
[patient] sure .
[doctor] all right . hey , Sarah , finalize the note . | CHIEF COMPLAINT
Follow-up of chronic problems.
HISTORY OF PRESENT ILLNESS
Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow-up of his chronic problems.
The patient states he has been feeling out of sorts lately. He is not sure if it is due to the change in the seasons or due to performing lots of projects and some construction on his home. He reports fatigue and lightheadedness. This has been going on for about 5 weeks. While exerting energy, he has experienced some shortness of breath and chest cramps. The patient also notes a slight cough, but he is not sure if it is just the change in seasons.
He feels bloated every once in a while. His diet has been a little bit of a struggle. They had construction on their kitchen begin over Labor Day weekend, and have been eating less healthy food as a result.
Regarding his heart failure, he has been pretty good with his salt intake. He has been pretty good about his diet since the last year and is staying on top of that as much as possible. The patient has continued to utilize Lasix daily.
For his hypertension, this has been well controlled with lisinopril 20 mg a day. He has continued to monitor his blood pressure regularly.
The patient did the review of systems sheet when he checked in. He denies weight gain, swelling in the lower extremities, fevers, chills, dizziness, nausea, vomiting, and diarrhea.
REVIEW OF SYSTEMS
• Constitutional: Endorses fatigue. Denies fevers, chills, or weight loss.
• Cardiovascular: Endorses chest pain or dyspnea on exertion.
• Respiratory: Endorses cough and shortness of breath.
• Gastrointestinal: Endorses bloating.
PHYSICAL EXAMINATION
• Neck: JVD 8 cm.
• Respiratory: Rales bilateral bases.
• Cardiovascular: 3/6 systolic ejection murmur.
• Musculoskeletal: 1+ pitting edema bilateral lower extremities.
RESULTS
X-ray of the chest demonstrates a mild amount of fluid in the lungs.
Echocardiogram demonstrates decreased ejection fraction of 45% and mild mitral regurgitation.
ASSESSMENT AND PLAN
Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow up of his chronic problems.
Congestive heart failure.
• Medical Reasoning: The patient reports increased fatigue, dizziness, and chest discomfort on exertion. He also exhibits some jugular venous distention, lung base crackles, and lower extremity edema on exam today. He has been compliant with his current medications but admits to dietary indiscretion lately. His recent echocardiogram demonstrated a reduced ejection fraction of 45%, as well as mitral regurgitation.
• Additional Testing: We will order a repeat echocardiogram.
• Medical Treatment: Increase Lasix to 80 mg daily.
• Patient Education and Counseling: I advised the patient to monitor and record his daily weight and report those to me via the patient portal. He will contact me should he continue to experience any dyspnea.
Hypertension.
• Medical Reasoning: This is well controlled based on home monitoring.
• Medical Treatment: Continue lisinopril 20 mg daily.
• Patient Education and Counseling: I advised him to monitor and record his blood pressures at home and report these to me via the patient portal.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N069 | virtassist | [doctor] hi , ms. thompson . i'm dr. moore . how are you ?
[patient] hi , dr. moore .
[doctor] hi .
[patient] i'm doing okay except for my knee .
[doctor] all right , hey , Sarah , ms. thompson is a 43 year old female here for right knee pain . so tell me what happened with your knee ?
[patient] well , i was , um , trying to change a light bulb , and i was up on a ladder and i kinda had a little bit of a stumble and kinda twisted my knee as i was trying to catch my fall .
[doctor] okay . and did you injure yourself any place else ?
[patient] no , no . it just seems to be the knee .
[doctor] all right . and when did this happen ?
[patient] it was yesterday .
[doctor] all right . and , uh , where does it hurt mostly ?
[patient] it hurts like in , in , in the inside of my knee .
[doctor] okay .
[patient] right here .
[doctor] all right . and anything make it better or worse ?
[patient] i have been putting ice on it , uh , and i've been taking ibuprofen , but it does n't seem to help much .
[doctor] okay . so it sounds like you fell a couple days ago , and you've hurt something inside of your right knee .
[patient] mm-hmm .
[doctor] and you've been taking a little bit of ice , uh , putting some ice on it , and has n't really helped and some ibuprofen . is that right ?
[patient] that's right . yeah .
[doctor] okay , let's review your past history for a second . it looks like , uh , do you have any other past medical history ?
[patient] uh , afib .
[doctor] okay , and are you taking any medications for that ?
[patient] yeah , i am . um , begins with a d.
[doctor] uh , digoxin ?
[patient] that's it . yeah , that's it .
[doctor] okay , all right . how about any surgeries in the past ?
[patient] i have had a nose job .
[doctor] all right . um , let's do your exam , okay ? so is it tender ... where is it mostly tender right now ?
[patient] right on the inside of my knee . right here .
[doctor] all right , so if i bend your knee forward , does that seem to hurt ?
[patient] yes , that hurts .
[doctor] all right , how about if i twist it a little bit that way .
[patient] that hurts a lot .
[doctor] okay , okay . and how about down here ? do you feel me touch you down here ?
[patient] yes .
[doctor] all right . any other pain down here in your calves ?
[patient] no .
[doctor] no , okay . so on exam you do have some tenderness over the medial portion of your knee over the medial meniscus area . uh , there is no , uh , there is a little bit of tenderness when i flex your , uh , when i , uh , uh , do some valgus stressing on your , on your leg . um , you have normal sensation . so let's take a look at your x-rays .
[patient] okay .
[doctor] okay . hey Sarah , show me the x-rays . so looking at the x-ray , um , of your left knee , uh , it appears to be there's no fractures there right now . i do n't see any , uh , there's a little bit of , uh , fluid , uh , but there is no , uh , there's no , um , fracture or there's no dislocation . everything else seems to be lined up properly , okay ?
[patient] okay .
[doctor] so in summary after my exam , uh , looking at your knee , uh , on the x-ray and your exam , you have some tenderness over the medial meniscus , so i think you have probably an acute medial meniscus sprain right now or strain . uh , at this point , my recommendation would be to put you in a knee brace , uh , and we'll go ahead and have you use some crutches temporarily for the next couple days . we'll have you come back in about a week and see how you're doing , and if it's not better , we'll get an mri at that time .
[patient] okay .
[doctor] i'm going to recommend we give you some motrin , 800 milligrams . uh , you can take it about every six hours , uh , with food . uh , and we'll give you about a two week supply .
[patient] okay .
[doctor] okay . uh , do you have any questions ?
[patient] no , i think i'm good .
[doctor] all right . hey , Sarah , order the medications and procedures discussed , and finalize the report . okay , come with me and we'll get you checked out . | CC:
Right knee pain.
HPI:
Ms. Thompson is a 43-year-old female who presents today for an evaluation of right knee pain. She states she was trying to change a lightbulb on a ladder, and she twisted her knee when she stumbled and caught herself from falling yesterday. She has been applying ice and taking Ibuprofen without relief.
CURRENT MEDICATIONS:
Ibuprofen, digoxin.
PAST MEDICAL HISTORY:
Atrial fibrillation.
PAST SURGICAL HISTORY:
Rhinoplasty.
EXAM
Examination of the right knee shows pain with flexion. Tenderness over the medial joint line. No pain in the calf. Pain with valgus stress. Sensation is intact.
RESULTS
X-rays of the right knee show no obvious signs of acute fracture or dislocation. Mild effusion is noted.
IMPRESSION
Right knee acute medial meniscus sprain.
PLAN
At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a knee brace. She will take Motrin 800 mg, every 6 hours with food, for two weeks. She will use crutches for the next couple of days. She will follow up with me in 1 week for a repeat evaluation. If she is not better at that time, we will obtain an MRI. All questions were answered.
|
D2N070 | virtassist | [doctor] hi logan . how are you ?
[patient] hey , good to see you .
[doctor] it's good to see you as well .
[doctor] so i know the nurse told you about dax .
[patient] mm-hmm .
[doctor] i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain .
[patient] mm-hmm .
[doctor] so logan , what happened to your back ?
[patient] uh , we were helping my daughter with some heavy equipment and lifted some boxes a little too quickly , and they were a little too heavy .
[doctor] okay ... and did you strain your back , did something-
[patient] i thought i heard a pop when i moved and i had to lie down for about an hour before it actually relieved the pain . and then it's been a little stiff ever since . and this was- what , so today's tuesday . this was saturday morning .
[doctor] okay , all right .
[doctor] and is it your lower back , your upper back ?
[patient] my lower back .
[doctor] your lower back , okay . and what- what have you taken for the pain ?
[patient] i took some tylenol , i took some ibuprofen , i used a little bit of icy heat on the spot but it really did n't seem to help .
[doctor] okay . and um ... do you have any numbing or tingling in your legs ?
[patient] uh ... i felt some tingling in my toes on my right foot until about sunday afternoon . and then that seemed to go away .
[doctor] okay , and is there a position that you feel better in ?
[patient] uh ... it's really tough to find a comfortable spot sleeping at night . i would- i tend to lie on my right side and that seemed to help a little bit ?
[doctor] okay , all right .
[doctor] well , um ... so how are you doing otherwise ? i know that , you know , we have some issues to talk-
[patient] mm-hmm .
[doctor] . about today . were you able to take any vacations over the summer ?
[patient] um ... some long weekends , which was great . just kind of- trying to mix it up through the summer . so lots of three day weekends .
[doctor] okay , well i'm glad to hear that .
[doctor] um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ...
[patient] yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar .
[patient] and uh ... i-i think i need to go clean for a couple of weeks . but other than that , it was been- it's been pretty good eating .
[doctor] okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ?
[patient] i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , but it's been pretty good and-and under control for the most part .
[doctor] okay , and you're you're taking your medication ?
[patient] yes , i am .
[doctor] okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ?
[patient] uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . not great , but it's been okay .
[doctor] okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain .
[doctor] have you had any other symptoms , chest pain , nausea or vomiting-
[patient] no .
[doctor] . fever , chills ?
[patient] no . no none whatsoever .
[doctor] no . okay . all right , well let me go ahead , i want to do a quick physical exam .
[patient] mm-hmm .
[doctor] hey Sarah ? show me the blood pressure .
[doctor] so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your-
[patient] mm-hmm .
[doctor] . blood pressure go up . let's look at the readings .
[doctor] hey Sarah ? show me the blood pressure readings .
[doctor] yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well .
[patient] mm-hmm .
[doctor] okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ?
[patient] sure .
[doctor] and kick against my hands .
[doctor] okay , good . all right .
[doctor] okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur .
[patient] mm-hmm .
[doctor] on your heart exam . which you've had in the past .
[patient] mm-hmm .
[doctor] so that sounds stable to me .
[doctor] on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ?
[patient] mm-hmm .
[doctor] hey Sarah ? show me the diabetes labs .
[doctor] okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ?
[patient] sure .
[doctor] hey Sarah ? show me the back x-ray .
[doctor] so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on-
[patient] mm-hmm .
[doctor] . the history , okay ?
[patient] mm-hmm .
[doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you .
[doctor] so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day .
[patient] mm-hmm .
[doctor] i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy-
[patient] mm-hmm .
[doctor] . and see how you do , okay ?
[patient] you got it .
[doctor] for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ?
[patient] mm-hmm .
[doctor] hey Sarah ? order a hemoglobin a1c .
[doctor] so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day .
[patient] mm-hmm .
[doctor] does that sound okay ? i think we need to get it under better control .
[patient] no that's fine . i agree .
[doctor] hey Sarah ? order lisinopril 20 mg daily .
[doctor] and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ...
[patient] mm-hmm .
[doctor] i do n't think we need to do any- any further , you know , work up of that at this time , okay ?
[patient] mm-hmm .
[doctor] do you have any questions logan ?
[patient] not at this point .
[doctor] okay . all right .
[doctor] so the nurse will come in to help you get checked out , okay ?
[patient] you got it .
[doctor] hey Sarah ? finalize the note . | CHIEF COMPLAINT
Back pain.
HISTORY OF PRESENT ILLNESS
Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with back pain.
Mr. Walker reports that he was helping his daughter move some heavy equipment and lifted some heavy boxes a little too quickly on Saturday. He thought he heard a pop when he moved and he had to lie down for about an hour before his pain resolved. He has had stiffness ever since. The pain is located in his lower back. He took Tylenol, ibuprofen, and used Icy Hot on the area, but it did not seem to help. The patient endorses some tingling in his toes on his right foot, which resolved Sunday afternoon. He finds it difficult to find a comfortable position to sleep at night, and he tends to lie on his right side, which seems to help a little bit.
Regarding his diabetes type 2, Mr. Walker reports that he has not cooked a meal at home in weeks, due to travel. He notes that his diet has not been great, and he thinks he needs to eat clean for a couple of weeks.
He monitors his blood pressure at home and it is under control for the most part.
Regarding his osteoarthritis, Mr. Walker reports occasional aggravation of his knee when he runs too much or lifts boxes that are too heavy.
The patient denies chest pain, nausea, vomiting, fevers, and chills.
REVIEW OF SYSTEMS
• Constitutional: Denies fevers, chills.
• Cardiovascular: Denies chest pain.
• Musculoskeletal: Endorses back pain and stiffness. Endorses knee pain with exertion.
• Neurological: Endorsed tingling in toes until Sunday, denies tingling today.
PHYSICAL EXAMINATION
• Cardiovascular: Slight 2/6 systolic ejection murmur.
• Musculoskeletal: Pain to palpation of the lumbar spine. Pain with flexion and extension of the back. Negative straight leg raise.
VITALS REVIEWED
• Blood Pressure: Elevated
RESULTS
Hemoglobin A1c is elevated at 8.
X-ray of the back is unremarkable. Normal bony alignment. No fracture present.
ASSESSMENT AND PLAN
Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with low back pain.
Lumbar strain.
• Medical Reasoning: He injured his lower back while moving heavy boxes. His recent x-ray was unremarkable.
• Medical Treatment: Initiate meloxicam 15 mg once a day.
• Specialist Referrals: Referral to physical therapy.
• Patient Education and Counseling: He was encouraged to continue icing the area and avoid strenuous activity.
Diabetes type 2.
• Medical Reasoning: His recent hemoglobin A1c was elevated at 8. He does admit to some dietary indiscretion lately.
• Additional Testing: Repeat hemoglobin A1c in 6 months.
• Medical Treatment: Increase metformin to 1000 mg twice a day.
Hypertension.
• Medical Reasoning: His blood pressures have been slightly elevated based on home monitoring and in clinic today.
• Medical Treatment: Increase lisinopril from 10 mg to 20 mg a day.
Osteoarthritis.
• Medical Reasoning: This is mostly well controlled.
• Medical Treatment: Continue to monitor the knee. No further work up is needed at this time.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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D2N071 | virtassist | [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 , Sarah , 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 , Sarah , 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 , Sarah , 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 , Sarah , 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 , Sarah , 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 , Sarah , 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 , Sarah , finalize the note . the nurse will be in .
[patient] thank you . | CHIEF COMPLAINT
Annual exam.
HISTORY OF PRESENT ILLNESS
The patient is a 62-year-old male with a past medical history significant for depression and prior lobectomy, as well as hypertension. He presents for his annual exam.
The patient reports that he is doing relatively well. Over the summer, he moved his oldest daughter into college which was a little stressful and chaotic in the heat of the summer.
Regarding his depression, he reports that he has been consistent with his Prozac and has not had any incidents in a while.
His hypertension has been slightly uncontrolled. He reports that he is taking his blood pressure at home and it is running high. The patient states that he is pretty regular with his Norvasc during the business week, but on the weekends he will forget to bring it with him.
He reports that he had a prior lobectomy a couple of years ago. He endorses shortness of breath with exertion. The patient has difficulty breathing due to allergies and the heat in the summertime. He also endorses some nasal congestion from the pollen. He reports that he runs in the morning. Occasionally, if it is relatively humid, he will struggle a little bit with breathing and he will feel a little bit of a pounding in his chest. He states that it usually goes away. He reports that he runs 4 to 5 miles a day.
REVIEW OF SYSTEMS
• Ears, Nose, Mouth and Throat: Endorses nasal congestion from the pollen.
• Cardiovascular: Endorses intermittent palpitations. Endorses dyspnea on exertion.
• Respiratory: Endorses shortness of breath. Endorses cough.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Head and Face: Pain to palpation to the sinuses.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate. 2/6 systolic ejection murmur. No gallops or rubs. No extra heart sounds.
VITALS REVIEWED
• Blood Pressure: 124/80 mmHg.
RESULTS
Electrocardiogram stable.
X-ray of the chest is unremarkable.
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.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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D2N072 | virtassist | [doctor] hi , ms. brooks . i'm dr. baker . how are you ?
[patient] hi , dr. baker .
[doctor] is your , is your right finger hurting ?
[patient] yes .
[doctor] okay . hey , Sarah , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened .
[patient] well , i was skiing over the weekend-
[doctor] okay .
[patient] . and as i was , um , coming down the hill , i tried moguls , which jumping over those big hills , i tend to get my strap caught on my finger-
[doctor]
[patient] . and it kind of bent it back a bit .
[doctor] okay .
[patient] yeah .
[doctor] and when did this happen ?
[patient] it happened , uh ... that was sunday .
[doctor] okay . and have you tried anything for this or anything made it better or worse ?
[patient] i tried , um , putting ice on it .
[doctor] okay .
[patient] uh , and then i- i've been taking ibuprofen , but it's still very painful .
[doctor] okay . and , uh , is it worse when you bend it ? or anything make it ... so , just wh-
[patient] yeah , movement .
[doctor] okay .
[patient] yes .
[doctor] okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ?
[patient] um , i have been suffering from constipation recently .
[doctor] okay . all right . and do you take ... what medicines do you take for constipation ?
[patient] um , i've just been taking , um , mel- um ...
[doctor] miralax ?
[patient] miralax . that's it .
[doctor] okay . miralax is sufficient .
[patient] miralax . yes .
[doctor] and any surgeries in the past ?
[patient] i did have my appendix taken out when i was 18 .
[doctor] okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ?
[patient] no .
[doctor] okay . and how'bout right there ? no ?
[patient] no .
[doctor] right here ?
[patient] that hurts .
[doctor] all right . uh , can you bend your finger for me ?
[patient] yeah .
[doctor] all right . and how about extend it ? all right . and can you touch your thumb with it ?
[patient] yes .
[doctor] all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have some pain flexion as well . so , let's look at your x-rays . hey , Sarah , show me the x-rays .
[doctor] all right . so , on this x-ray.
everything looks normal right now . uh , i do n't see any fractures . everything lines up pretty well . uh , so , your x-ray looks normal with no fractures . so , based on the x-ray and your exam , you have some tenderness right here . i think you've got a little contusion right here . there's no fracture on the tip of your finger . uh , so , the diagnosis would be a right hand , uh , index finger contusion on the tip of your finger , okay ? so , i would recommend we get you a s- uh , aluminum foam splint and we'll get you some motrin . uh , we'll give you 600 milligrams every six hours and we'll take that for about a week . and if it does n't get better , why do n't you call us and come back at that point ?
[patient] okay .
[doctor] okay . do you have any questions ?
[patient] no . i think that sounds good .
[doctor] okay . hey , Sarah , order the medication and procedures we discussed . all right . and why do n't you come with me and we'll get you signed out .
[patient] okay . thank you .
[doctor] all right . finalize report , Sarah . | CC:
Right finger pain.
HPI:
Ms. Brooks is a 48-year-old female who presents today for an evaluation of right finger pain. She states she was skiing on Sunday and hyperextended her finger when it became caught in a strap on a jump. She has tried applying ice and taking Ibuprofen, but it is still very painful. She has pain with movement.
CURRENT MEDICATIONS:
MiraLax
PAST MEDICAL HISTORY:
Constipation.
PAST SURGICAL HISTORY:
Appendectomy.
EXAM
Examination of the right index finger shows tenderness over the distal phalanx. No tenderness over the proximal phalanx or the MP joint. Pain with flexion.
RESULTS
X-rays of the right hand show no obvious signs of fracture or bony abnormalities.
IMPRESSION
Right hand index finger contusion at the tip of the finger.
PLAN
At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. She will take Motrin 600 mg every 6 hours for a week. If she does not improve, she will follow up with me. All questions were answered.
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D2N073 | virtscribe | [doctor] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia .
[doctor] hello , how are you ?
[patient] i'm good , thank you .
[doctor] so tell me what brings you in today .
[patient] recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic .
[doctor] or how have you been feeling in general with this ?
[patient] not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me .
[doctor] okay . are there any other symptoms ?
[patient] i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess .
[doctor] sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ?
[patient] yeah , i've been anemic since i was 13 years old .
[doctor] right . so why do your doctors think you're anemic ? do you have a history of heavy periods ?
[patient] well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly .
[doctor] yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ?
[patient] about five to six years ago .
[doctor] and was it relatively a normal exam ? did you have any polyps ?
[patient] no . they said they'd see me in 10 years .
[doctor] well that's good news .
[patient] yeah , i agree .
[doctor] um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ?
[patient] no .
[doctor] all right . do you ever drink alcohol ?
[patient] yeah , but only once or twice a year .
[doctor] okay . are you taking any supplements such as iron or vitamin b12 ?
[patient] i already started taking my iron pills which i have not taken in about a year .
[doctor] all right . and what are you taking ?
[patient] i'm taking 25 milligram tablets , twice daily .
[doctor] okay , and that's the , the ferrous sulfate ?
[patient] yeah , that's it . i take one in the morning and one in the evening .
[doctor] okay . anything else ?
[patient] yeah , i take vitamin b12 , just the over the counter stuff .
[doctor] okay , very good . all right , well let's go ahead and take a look and see what's going on .
[patient] sounds good . thank you .
[doctor] of course . you'll hear me , uh , talk through your exam so that i get all the information documented .
[patient] okay .
[doctor] all right . so use my general physical exam template . i will start by listening to your heart and lungs .
[patient] okay .
[doctor] all right . next , i'd like you to lay back so i can examine your abdomen .
[patient] okay .
[doctor] is there any tenderness where i'm pressing ?
[patient] no .
[doctor] okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding .
[patient] is that why they want me to have another upper endoscopy ?
[doctor] actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why .
[patient] lovely .
[doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system .
[patient] okay .
[doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better .
[patient] all right .
[doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled .
[patient] okay .
[doctor] um , have you ever had any issue with sedation in the past ?
[patient] no , i was just sleepy afterwards .
[doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy .
[patient] okay . sounds like a plan .
[doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work .
[patient] okay , that sounds great .
[doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you .
[patient] thank you .
[doctor] you're welcome . have a great day , have a great day ms. cooper .
[patient] you too .
[doctor] all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks . | CHIEF COMPLAINT
Iron deficiency anemia.
HISTORY OF PRESENT ILLNESS
Mrs. Christina Cooper is a 65-year-old female who presents with a long-history of iron deficiency anemia.
The patient reports she has been living with anemia since she was 13 years old. She attempted to donate blood on 12/2019 but was unable to due to her anemia. She has a history of heavy menstruation and a hysterectomy in 1996. She completed a colonoscopy 5-6 years ago with nonsignificant findings. She denies having a pacemaker, defibrillator, sleep apnea, or using oxygen.
Mrs. Cooper reports a myriad of symptoms, stating she feels fatigued often during the day, feverish with chills at times, and during activity feels she cannot catch her breath and some wheezing is present. She has been having some headaches which is uncommon for her. Additionally, she is noticing tingling sensations, cold sensitivity, and her anxiety and depression have worsened.
PAST HISTORY
Surgical
Hysterectomy, 1996.
Procedures
Colonoscopy 5-6 years ago.
SOCIAL HISTORY
Drink’s alcohol 1-2 times per year.
CURRENT MEDICATIONS
Ferrous Sulfate 25 mg tablet twice per day (1 in the morning, 1 in the evening), Vitamin B12 OTC.
PHYSICAL EXAM
Gastrointestinal
Abdomen non-tender.
ASSESSMENT
• Iron deficiency anemia
Mrs. Cooper is a 65-year-old female who was diagnosed with iron deficiency anemia in 12/2019 and was unable to donate blood. Her follow-up blood work in 01/2020 revealed a low hemoglobin, stable hematocrit, and normal iron labs, although, ferritin was low. She has been taking ferrous sulfate 325 mg by mouth.
PLAN
I have asked her to continue each ferrous sulfate dose with vitamin C found in orange juice for the next 12 weeks then recheck CBC, iron ferritin, B-12, and folate. A referral was sent for her to see a hematologist. We will plan for EGD and colonoscopy to assess for potential sources of anemia or GI bleed. If this is inconclusive, capsule endoscopy can be considered.
INSTRUCTIONS
Schedule upper endoscopy, colonoscopy and appointment with hematologist. Return to the clinic if symptoms worsen. |
D2N074 | virtscribe | [doctor] patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable .
[doctor] worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . the mri reveals a pituitary lesion with elevation and compression of the optic chiasm . the ventricles are normal in size and no other abnormalities are lo- are noted .
[doctor] hello , mr . ward . nice to meet you . i'm dr. flores .
[patient] hi , doc . nice to meet you .
[doctor] i was just reviewing your records from dr. howard and he's referred you because the workup for headaches revealed a mass on your pituitary gland . i did review your mri images and you have a significant mass there . can you tell me about the issues you've been experiencing ?
[patient] yeah sure . so i'm really getting fed up with these headaches . i've been trying my best to deal with them but they've been going on for months now and i'm really struggling .
[doctor] where are the headaches located and how would you describe that pain ?
[patient] located behind my eyes . it's like a dull nagging ache .
[doctor] okay . was the onset gradual or sudden ?
[patient] well it started about three months ago . and they've been getting worse over time . at first it was like three out of 10 severity , and it just gradually worsened . and now it's about six out of 10 severity . the headaches do tend to be worse in the morning and it feels like a dull ache behind the eyes . they last a few hours at a time , nothing makes them better or worse .
[doctor] okay . can you tell me if the pain radiates , or if you have any other symptoms ? specifically feeling sick , fever , rashes , neck stiffness , numbness , weakness , passing out ?
[patient] no . i have n't been sick or felt sick . ca n't recall a fever or any kind of rash . no- no neck issues , no numbness , no tingling . and i've never passed out in my life . but , um , for some reason recently i seem to be bumping into door frames .
[doctor] okay . have you noticed any change in your vision or with your balance ?
[patient] no i do n't think so . my eyes were checked in the fall .
[doctor] okay . let's see , do you have any other medical problems that you take medicine for ?
[patient] no i do n't have any medical problems and i do n't take any medicines . i tried tylenol a few times for the headaches but it did n't work , so i stopped .
[doctor] i see . anyone in your family have any history of diseases ?
[patient] i was adopted so i really have no idea .
[doctor] okay . um , what kind of work do you do ? and are you married ?
[patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house .
[doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ?
[patient] nope . i do n't do any of those and never have .
[doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done .
[patient] sounds good , doc .
[doctor] all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . visual field testing reveals bitemporal hemianopia . and color vision is normal .
[doctor] all right , mr. ward . i'm going to review these pictures from the mri with you . um , now this appears to be a benign pituitary adenoma , but there's no way to be sure without sending the removed adenoma to pathology to make the diagnosis , which we will do . um , here you can see it's a well defined mass . and it's pressing right here on what we call the optic chiasm . and today when i was having you look at my fingers , you could n't see them off to the sides , that's what we call bitemporal hemianopia . and explains why you have been bumping into door frames .
[patient] yeah i never noticed that i could n't see out of the side until you did that test , and you closed one eye with both eyes . i really could n't tell .
[doctor] no because you're having this vision loss from the mass compressing the optic chiasm , the only option we have is to do surgery .
[patient] okay , i understand . do you think i'll regain my vision ?
[doctor] well there's no guarantees , but it is a possibility . i'm gon na refer you to the eye doctor for a full exam and they'll do what's called visual field test . this will map our your peripheral vision or side vision prior to surgery . and we can monitor after surgery to see if your vision is improving .
[patient] all right .
[doctor] and let's discuss the surgery a little more . um , we would do what's called a transsphenoidal approach to do the surgery . this is minimally invasive and we go through the sphenoid sinus . there are some risks i have to inform you of . uh , risk of anesthesia including but not limited to the risk of heart attack , stroke , and death . risk of surgery include infection , need for further surgery , wound issues such as spinal fluid leak or infection , uh , which may require long , prolonged hospitalization or additional procedure . uh , seizure , stroke , permanent numbness , weakness , difficulty speaking , or even death .
[patient] well i guess we have to do it regardless .
[doctor] okay . so i will have you see our surgery scheduler , deborah , on the way out to get you set up . we will get this scheduled fairly quickly so i do n't want you to be alarmed . um , she'll also get you set up today or tomorrow to have the visual field test and you may not be able to see the eye doctor until after surgery . but we have the pre-surgery visual field test for comparison after surgery .
[patient] okay . i look forward to these headaches going away . i never thought it could be something like this going on .
[doctor] yeah . come this way , we'll get your things lined up . please call if you think of any questions .
[patient] thanks , doctor .
[doctor] diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note . | CHIEF COMPLAINT
Pituitary lesion.
HISTORY OF PRESENT ILLNESS
Bruce Ward is a 52-year-old male with a pituitary lesion. The patient is seen in consultation at the request of Dr. Henry Howard for possible surgical intervention.
The patient presented to his primary care provider, Dr. Howard, on 03/01/2021 complaining of worsening headaches over the past few months. He denied any trouble with headaches in the past. Further work up of headaches with MRI of the brain revealed the pituitary lesion.
Mr. Ward reports headaches started about 3 months ago, at which point they were around 3 out of 10 in severity. They have gradually worsened over time and now he rates them at about 6/10. The headaches do tend to be worse in the morning and feel like a dull ache behind the eyes. They tend to last a few hours at a time, and nothing makes them particularly worse or better. Tylenol failed to improve headaches.
The patient endorses that recently he has been bumping into door frames, but no obvious problems with his balance or vision. He denies any recent sickness or feeling sick and negative for fever, rash, paresthesia, weakness, neck stiffness, or syncope.
PAST HISTORY
Medical
Newly diagnosed pituitary lesion.
FAMILY HISTORY
No known family history; adopted.
SOCIAL HISTORY
Employment Status: Works as a computer programmer.
Marital Status: Married for 25 years.
Living Arrangement: Lives with wife, recently purchased a new house.
Alcohol Use: None.
Tobacco Use: Non-smoker.
Recreational Drugs: None.
PHYSICAL EXAM
Neurological
Patient alert, oriented to person, place, and time, affect appropriate and speech fluent. Cranial nerve examination grossly intact. No focal motor or sensory deficit in the upper or lower extremities.
Eyes
Visual acuity and eye movements are normal. Pupils are equal and reactive. Visual field testing reveals bitemporal hemianopia. Color vision is normal.
RESULTS
Labs reviewed, 03/03/2021: CBC, U&Es, coagulation, and CRP are all normal. Pituitary hormone profile demonstrates a low TSH, all other results were normal.
Independent review and interpretation of MRI brain, 03/04/2021: The MRI reveals a pituitary lesion with elevation and compression of the optic chiasm. The ventricles are normal in size and no other abnormalities are noted.
ASSESSMENT
• Pituitary adenoma
• Bitemporal hemianopia
Mr. Ward is a very pleasant 52-year-old male who has a benign appearing pituitary adenoma discovered on work up for worsening headaches. There is clinical and radiographical evidence of optic chiasmal compression, examination today revealed a bitemporal hemianopia. Radiographically this appears to be a benign pituitary adenoma but that there was no way to be sure without a pathological diagnosis. Surgical intervention to excise and decompress the pituitary fossa is indicated given optic chiasmal compression.
PLAN
Pituitary adenoma.
We discussed the general indications for surgical intervention. The risks, benefits to trans-sphenoidal resection were explained to the patient. The risks of anesthesia including but not limited to the risks of heart attack, stroke, and death. The risks of surgery including infection, need for further surgery, wound issues (such as spinal fluid leak or infection) which may require prolonged hospitalization or additional procedure, seizure, stroke, permanent numbness, weakness, difficulty speaking, or death. The patient voiced understanding and wishes to proceed with trans-sphenoidal resection of the adenoma.
Bitemporal hemianopia.
We will have the patient scheduled this week to have visual field testing with ophthalmology. The preoperative visual field will serve as baseline for comparison of postoperative visual field testing to monitor for improvement in the bitemporal hemianopia. Additionally, we discussed that unfortunately no guarantees could be given that his vision would return.
INSTRUCTIONS
• Refer to ophthalmology for baseline visual field testing.
• Schedule trans-sphenoidal resection of pituitary adenoma.
|
D2N075 | virtscribe | [doctor] next is betty hill , uh , date of birth is 2/21/1968 . she has a past medical history of uterine fibroids and anemia . she's a new patient with a referral from the er of esophagitis . um , i reviewed our records from the er , including the normal cardiac workup , and we're about to go in and see her now . good morning . you miss hill ?
[patient] good morning . yes . that's me .
[doctor] hey , i'm dr. sanders . it's nice to meet you .
[patient] nice to meet you too .
[doctor] so tell me about what brings you in today ?
[patient] well , i really needed to see you three months ... three months ago , but this was your first available appointment . when i called to make the appointment , i was having chest pains , but it stopped after four days , and i have n't had any since then .
[doctor] okay . when did these four days of chest pain occur ?
[patient] um , early october .
[doctor] of 2020 , correct ?
[patient] yes .
[doctor] okay . can you think of anything that might have caused the chest pain ? did you wake up with it ?
[patient] no . it just it randomly . i tolerated it for four days but then had to go to the emergency room because nothing i did relieved it . they did a bunch of testing and did n't find anything .
[doctor] okay . can you point to the area of your chest where the pain was located ?
[patient] well , it was here in the center of my chest , right behind my breastbone . it felt like i was having a heart attack . the pain was really sharp .
[doctor] did they prescribe you any medications in the er ?
[patient] no . they ran an ekg and did blood tests , but like i said , everything was normal .
[doctor] okay . i see .
[patient] they thought it was something to do with the gi system , so that's why they referred me here .
[doctor] interesting . uh , do you remember having any heartburn or indigestion at , at the time ?
[patient] uh , maybe . i do n't think i've ever had heartburn , so i'm not sure what that feels like .
[doctor] was the pain worse with eating or exercise ?
[patient] yes . with eating .
[doctor] okay . any difficulty swallowing ?
[patient] mm-hmm . i did .
[doctor] okay . and that's also resolved since the initial episode three months ago ?
[patient] yes . thankfully . the chest pain and swallowing problem got better about three days after i went to the er . but i just feel like there's something wrong .
[doctor] okay . so how has your weight been .
[patient] i've been trying to lose weight .
[doctor] that's good . any in- ... issues with abdominal pain ?
[patient] uh , no .
[doctor] okay . good . and how about your bowel movements ; are they okay ?
[patient] they're normal .
[doctor] all right . are you aware of any family history of gi problems ?
[patient] i do n't think so .
[doctor] have had you had any surgeries on your abdomen , or gall bladder , or appendix ?
[patient] yes . they took my gall bladder out several years ago .
[doctor] okay . if you wan na lay down here on the table for me and lets take a look at you .
[patient] okay .
[doctor] so when i push on your lower belly , do you have any pain , or does it feel tender ?
[patient] no .
[doctor] okay . how about up here in your upper abdomen ?
[patient] yes . it , it hurts a little .
[doctor] okay . and even when i press lightly like this ?
[patient] yes . uh , just a little uncomfortable .
[doctor] okay . does it hurt more when i press over here on the left or over here on the right ? or is it about the same ?
[patient] i'd say it's about the same .
[doctor] okay . so we'll say you have some mild tenderness to light palpation in the upper abdominal quadrants , but everything on your exam looks normal and looks good .
[patient] okay . good .
[doctor] so let's talk about your symptoms real quick . obviously , with the chest discomfort , we worry about heart issues , but i'm reassured that those were ruled out with all the testing they did in the er . um , other potential causes could be anxiety , esophagitis , which is irritation of the esophagus . but typically with these , um ... but typically , these cause the pain that would last for a long time rather than that isolated incident like you had . um , it's also possible that you had intense heartburn for a few days .
[patient] well , since you mention anxiety , i was going through a really stressful job transition right around the time this happened .
[doctor] okay . that's good to know . so stress from this could be , um ... could be , uh ... could be very well have contributed to your condition .
[patient] okay .
[doctor] so we could do an , uh , egd or upper endoscopy to take a look at your esophagus and stomach . this would allow us to look for esophagitis . but your symptoms occurred three months ago and you have n't had any additional episodes , so likely if it were esophagitis , it's already healed by the point ... by this point , and we would n't be able to see anything . the other option is just to continue to monitor , uh , for any additional symptoms at which point we could do the egd . uh , with you being asymptomatic for so long right now , i'm comfortable with that option . but what do you think ?
[patient] i'd like to hold off on the egd and wait to see if i have more symptoms .
[doctor] that sounds good . um , so you can call the office if you have any additional episodes of pain or any other symptoms you're concerned about . if that happens , we'll get you scheduled for an egd to take a look . if not , you can follow up with me ... follow up with me as needed for any other gi complaints .
[patient] okay .
[doctor] all right ? if you do n't have any questions for me , i'll walk you out to the check-out desk .
[patient] no . that's it . thank you .
[doctor] you're welcome . right this way . all right . uh , in assessment , please summarize the patient's history briefly , and let's list her possible etiologies such as , uh , gerd , dyspepsia , esophagitis , musculoskeletal etiologies , and anxiety . uh , suspect she had an anxiety attack related to her job transition , plus or minus a contribution from her musculoskeletal etiologies . um , in the plan , include our discussion of the egd versus monderning ... monitoring for symptom . patient elected to self-monitor her symptoms and will call with any reoccurrence or change . thanks . | CHIEF COMPLAINT
Esophagitis.
HISTORY OF PRESENT ILLNESS
Betty Hill is a 53 y.o. female who presents to clinic today for a new patient evaluation of suspected esophagitis. The patient was referred from the emergency department where she was seen in early 10/2020 following 4 days of chest pain. The pain has resolved but she kept this appointment to discuss the original 4-day episode.
The patient describes her chest pain in early 10/2020 as sharp and localized behind the sternum. She states that it felt like a heart attack and the onset was sudden. The pain was exacerbated by eating and accompanied by dysphagia. The patient is not able to say whether she had heartburn as she has never experienced heartburn before and is unsure what it feels like. When asked about potential triggers, the patient identifies that she was experiencing a lot of stress at that time due to a job transition. She was able to tolerate the chest pain and dysphagia for 4 days but reports that nothing she tried relieved her symptoms. She then presented to the emergency department and underwent labs and EKG. All results came back normal from these tests. She was not prescribed any medications in the emergency department but was given a referral to me for suspected esophagitis. Her chest pain and dysphagia resolved spontaneously approximately 3 days after her emergency department visit and has not recurred.
The patient denies unintentional weight loss, weight gain, abdominal pain, constipation, and diarrhea. She states she is trying to lose weight.
PAST HISTORY
Medical
Uterine fibroids.
Anemia.
Surgical
Cholecystectomy.
FAMILY HISTORY
None reported.
REVIEW OF SYSTEMS
• Cardiovascular: Positive for chest pain.
• Gastrointestinal: Positive for difficulty swallowing.
• Psychiatric: Positive for stress.
PHYSICAL EXAM
Gastrointestinal
Mild tenderness to light palpation in the upper abdominal quadrants.
RESULTS
The patient’s emergency department records from her 10/2020 visit were reviewed, including the normal cardiac workup.
ASSESSMENT
The patient presents today following a visit to the emergency department in early 10/2020 for 4-days of sharp chest pain, made worse by eating, and dysphagia. Notably, the patient was experiencing higher levels of stress than normal for her at that time due to a job transition. Her cardiac evaluation in the emergency department was normal and she was referred to me for suspected esophagitis. The patient’s pain and associated dysphagia spontaneously resolved 3 days after her emergency department visit and has not recurred. Possible etiologies of her chest pain and dysphagia include GERD, dyspepsia, esophagitis, musculoskeletal etiologies, and anxiety. Based on her history today, I suspect she had an anxiety attack related to her job transition, plus or minus a contribution from musculoskeletal etiologies.
Non-cardiac chest pain.
Suspected etiology of anxiety with or without underlying musculoskeletal etiology.
PLAN
• We discussed the role of an EGD in evaluating her prior symptoms. Given her current asymptomatic status, I am comfortable foregoing the EGD for now in lieu of continued monitoring for symptom recurrence. The patient agreed to notify my office if her symptoms return at which time, we could schedule the EGD. The patient is agreeable to this plan.
INSTRUCTIONS
• Self-monitor for symptom recurrence and notify my office if this occurs.
• Follow up as needed. |
D2N076 | virtscribe | [doctor] hello .
[patient_guest] hi .
[doctor] i'm dr. evelyn , one of the kidney doctors . it's good to meet you guys .
[patient_guest] it's nice to meet you also .
[doctor] yeah . so i was reading about this syndrome that i actually have never heard of .
[patient_guest] yeah , me too .
[doctor] i do n't think it's very common .
[patient_guest] definitely not . it's c- pretty rare .
[doctor] so-
[doctor] can you start at the beginning ? i know she's a twin , so are these your first two babies ?
[patient_guest] no , i have a son also who is nine . he also has autism .
[doctor] okay .
[patient_guest] and when the twins were born , katherine , she was about 4 pounds , 8 ounces . and her twin was a bit smaller , at 3 pounds , 13 ounces .
[patient_guest] katherine , she was doing fine . she just had problems with eating , where she would stop breathing when she was eating .
[doctor] like preemie type stuff ?
[patient_guest] uh- . yeah . she just had a hard time regulating her temperature , but she did fine . she does have a gi doctor , because she has reflex really bad . she also had a dietician , who told us to take her off cow's milk . which we did . and then she has seen an allergist , and also a neurologist ... who diagnosed her with this syndrome , because she still does n't walk and she was n't sitting by herself a year old .
[doctor] yeah .
[patient_guest] but so now she is crawling and she is trying to take steps , so think she's doing pretty good .
[doctor] good . is she in therapy ?
[patient_guest] she is in therapy . she's in feeding therapy , occupational therapy , and also physical therapy .
[doctor] awesome . okay .
[patient_guest] and we also have speech therapy , who is going to be starting within the next couple of weeks .
[doctor] that's great .
[patient_guest] so , she has a lot of therapies . we have also seen an orthopedic and an ophthalmologist . i can never say that . we have seen everything , really .
[doctor] and audiology too , right ?
[patient_guest] yes .
[doctor] yeah , wow. .
[patient_guest] yeah , it has definitely been a whirlwind of stuff . when we saw the geneticist , she told us that sometimes people with this syndrome , they have trouble with their kidneys . that they might actually fuse into one . she also said sometimes they have problems with their legs , so that was why we saw ortho .
[doctor] okay . okay .
[patient_guest] so we have seen everybody , really . we are just here to make sure that her kidneys are looking good right now .
[doctor] yeah , okay . so , um , tell me about how many wet diapers she has in a 24 hour period ?
[patient_guest] she has a lot .
[doctor] so like normal 8 to 10 , or like 20 ?
[patient_guest] yeah , it's around 8 to 10 .
[doctor] okay . great .
[patient_guest] yeah , she seems to pee a lot , and it feels like she drinks a lot too .
[doctor] that's perfect .
[patient_guest] and she used to only drink milk , and then i took her off dairy milk . so when i say milk , i actually mean , you know , ripple pea protein milk .
[doctor] sure , yeah .
[patient_guest] so i give her that milk , water now that she's used to it , and sometimes water with just a little bit of juice . so i do feel like she's drinking a lot better now .
[doctor] that's great . and she's how old now ?
[patient_guest] she'll be two mo- two next month .
[doctor] okay . is her twin a boy or a girl ?
[patient_guest] she's a girl .
[doctor] okay , and how's she doing ?
[patient_guest] she's doing really good . she's running around , and she does n't have any problems .
[doctor] all right . is she bigger than her or the same size ?
[patient_guest] they're about the same size . they're able to wear the same clothes , so ...
[doctor] okay .
[patient_guest] i do n't even think she's a pound hav- heavier , actually .
[doctor] yeah . yeah .
[patient_guest] but she is a little bit taller than her ... um , katherine . she's just sh- a little shorter and chunkier , but i think that's a part of her syndrome .
[doctor] yeah . yeah , i was reading all the things associated with the syndrome . it sounds like we're looking for continual- congenital anomalies wi- of the kidney and urinary tract . which is basically something is wrong with the plumbing .
[patient_guest] okay .
[doctor] so the only way to know that , is to do a kidney ultrasound .
[patient_guest] okay , that sounds okay .
[doctor] okay . let me put that into the system , and then downstairs they can do the ultrasound .
[patient_guest] all right , thank you .
[doctor] okay , yeah . where do you all live ?
[patient_guest] uh , we live in dallas .
[doctor] okay . anybody in the family with kidney failure , dialysis or transplant ?
[patient_guest] no .
[doctor] okay . so let's get your ultrasound done , and we'll see how it goes .
[patient_guest] all right , that sounds good .
[doctor] all right . let me take a quick look at her .
[patient_guest] sure .
[doctor] all right . please use my physical exam template . um , i wan na take a quick listen to her heart and lungs . i'll look in her ears too . and she can sit , she can just sit on your lap .
[patient_guest] okay .
[doctor] all right . that's it .
[patient_guest] all right , that was n't too bad .
[doctor] hmm . so , let's complete the ultrasound today . i'll call you with the results . if it's normal , you wo n't need to see me again , but if it's abnormal , you can see me in kennesaw .
[patient_guest] okay , that sounds good .
[doctor] okay . we'll determine what the next steps are if there are any , after we see her results .
[patient_guest] all right , sounds good . thank you .
[doctor] you're welcome . the nurse will be in to have you complete some paperwork , and give you instructions for the ultrasound . we'll talk soon .
[patient_guest] all right . thank you , and have a good day .
[doctor] you too .
[doctor] all right . physical exams show the well-nourished female , who is slightly fussy when examined . eyes are small appearing . she has mild hypotonia of the lower extremities in her arms . normal external female genitalia .
[doctor] assessment and plan . katherine is a 22-month-old former 34 and 3-week-old , twin with smith magenis syndrome . several organ systems can be affected by this chromosomal deletion syndrome . congenital anomalies of the kidney and urinary tract have been reported in the literature .
[doctor] we will obtain the screening of the kidneys by ultrasound today . if there are abnormalities on the kidney ultrasound , we will determine next steps and future follow-up . the family lives in dallas , georgia , so her follow-up should be at the town center location .
[doctor] end of recording . | CHIEF COMPLAINT
Renal screening tests.
HISTORY OF PRESENT ILLNESS
Katherine Lopez is a 22-month-old female, born at 34 weeks +3 days gestation, diagnosed with the rare Smith-Magenis syndrome and associated global developmental delays. She was referred to nephrology by genetics who recommended renal screening tests. At birth, the patient weighed 4 pounds 8 ounces, exhibited difficulties during eating where she would stop breathing, and challenges regulating her body temperature; determined to be typical issues associated with premature birth. The patient has seen many specialists, including GI for severe reflux, a dietitian who recommended discontinuing consumption of cow’s milk, and a neurologist who diagnosed her with Smith-Magenis syndrome. Additionally, she has been seen by a geneticist, orthopedist, ophthalmologist, and audiologist. The patient is not ambulatory, did not sit up unassisted until 1 years old, and is currently crawling and attempting to take steps. She will be starting speech therapy in the next few weeks, and currently she is in occupational, feeding, and physical therapy. The geneticist informed the patient's mother that patients with Smith-Magenis syndrome usually have kidney issues where “the kidneys fuse into one” and issues with their legs.
The patient has approximately 8 to 10 wet diapers in a 24-hour period. Her mother notes that she is doing better with drinking fluids and she urinates “a lot”. The patient drinks Ripple Pea Protein milk instead of cow’s milk, water and water mixed with a small amount of juice. Her twin sister is approximately the same size, and their weight is essentially the same, she is healthy, and the mom denies any known health concerns or diagnoses. The mom states that Katherine is shorter and seems chubbier related to her syndrome. She also has a 9-year-old brother who is diagnosed with autism.
BIRTH HISTORY
Twin gestation. Birth weight 4 pounds 8 ounces.
PAST HISTORY
Medical
Smith-Magenis syndrome.
SOCIAL HISTORY
Patient accompanied to appointment by her mother.
Sibling: 9-year-old brother and twin sister.
FAMILY HISTORY
Brother: 9 years old, positive for autism.
Twin sister: absence of Smith-Magenis syndrome, no known health conditions.
No known family history of genetic conditions, kidney failure, dialysis, or kidney transplant.
PHYSICAL EXAM
Constitutional
Well-nourished female, slightly fussy when examined.
Eyes
Presences of microphthalmia.
Genitourinary
Normal external female genitalia.
Musculoskeletal
Extremities: Presence of mild hypotonia of lower extremities and the arms.
ASSESSMENT
• Smith-Magenis syndrome.
Katherine is a 22-month-old former 34+3-week-old twin with Smith-Magenis syndrome.
Several organ systems can be affected by this chromosomal deletion syndrome and congenital anomalies of the kidney and urinary tract have been reported in the literature.
PLAN
We will obtain a kidney ultrasound screening today. If there are abnormalities on the kidney ultrasound, we will determine the next steps and future follow-up. The family lives in Dallas, Georgia, so her follow-up should be at the Town Center location.
INSTRUCTIONS
Complete ultrasound today. I will call patient with results and possible next steps. |
D2N077 | aci | [doctor] hey diana it's good to see you in here so i see that you injured your wrist could you tell me a bit about what happened
[patient] yeah i was walking up and down the stairs i was doing my laundry and i slipped and i tried to catch myself and i put my arms out to catch myself and then all of a sudden i just my wrist started to hurt real bad and it got real swollen
[doctor] wow okay so which wrist are we talking about left or right
[patient] it's my right one of course
[doctor] okay and then have you ever injured this arm before
[patient] no i have not
[doctor] okay alright so on a scale of one to ten how severe is the pain
[patient] gosh it's like a nine
[doctor] wow okay have you done anything to ease it
[patient] yeah i did the ice thing i put ice on it and then i you know i even i have a ace wrap at home i try to do that
[doctor] mm-hmm
[patient] and then i took some ibuprofen but it helps a little bit but it's just it's it's just not right
[doctor] okay
[patient] really
[doctor] yeah okay have you sorry i'm trying to think how long ago did this injury happen
[patient] this happened yesterday morning
[doctor] okay
[patient] maybe just you know i just bumped it but
[doctor] okay
[patient] it's just not it's really bad
[doctor] okay no i understand okay so i'm going so you said you were doing laundry
[patient] yes i had my back hit my basket and for some reason this cold started to kinda fall out a little bit i was trying to catch it i missed a step and i just totally
[doctor] okay alright any does the pain extend anywhere
[patient] no not really
[doctor] okay
[patient] it's just really along my wrist
[doctor] okay any numbness any tingling
[patient] a little one and one ca n't tell if it's just because of the swelling in my wrist but just i can like i can feel it my fingers still
[doctor] mm-hmm
[patient] but just maybe a little bit of tingling
[doctor] okay alright and are you so so okay i'm gon na think on this but in the meantime i'm gon na do my physical exam alright
[patient] okay
[doctor] okay so you know looking at your looking at your head and your neck i do n't appreciate any like adenopathy no thyromegaly no no carotid bruit looking at your listening to your heart i do n't appreciate any murmur no rub no gallop your lungs are clear to auscultation bilaterally your lower legs you have palpable pulses no lower edema your shoulders every like your upper extremities i see normal range of movement with your right wrist let's go ahead and focus on it so when i push on the inside here does it hurt
[patient] yes
[doctor] okay
[patient] it does
[doctor] and what about the outside does that hurt as well
[patient] yeah it does
[doctor] are you able to move your wrist towards your arm like
[patient] not without extreme pain
[doctor] okay so pain on flexion what about extension when you pick your wrist up
[patient] yeah i have a hard time doing that actually
[doctor] alright what about we're gon na go ahead and hold your arm like straight like flat and then try and move it sideways does radial deviation hurt
[patient] yeah
[doctor] alright and then lateral as well
[patient] yeah it's really hard to move any direction of this hand for some reason
[doctor] alright so wrist abduction adduction positive for pain on movement are you able to make a fist
[patient] hmmm yeah a little bit but i ca n't do it really tight
[doctor] okay alright okay so i'm just gon na go ahead and feel on your fingers really quickly alright metacarpals intact noticed some obvious swelling ecchymosis obvious swelling and bruising tenderness on palpation throughout there is evidence of potential fracture feeling some bony crepitus alright so this pain is it like chronic i wanted to ask you
[patient] yeah i would say it kinda goes away when i take that ibuprofen but for the most part i feel it i feel it there and it it's just really really bad when i move it all
[doctor] okay so when you like is there a position either hurts less or hurts more like say if your arm is raised and elevated over your head does it hurt more or is it just best to keep it like down
[patient] it's good if i keep it a little bit above my like a little i guess a little bit like around my like just a regular level like if you're typing or something and then i just put it on a pillow and i just let it stay straight like i feel better
[doctor] okay yeah no i do n't think i understand completely okay so i took a look at your vitals and your blood pressure is a little elevated but honestly that's probably to do with the pain right our body can respond to pain in that way we are looking at like a hundred and forty over over seventy it's not anything crazy but something to mention i see that your heart rate is also a little elevated at like about like eighty beats a minute you are not running a fever so that's great look at ninety ninety seven . two your respiratory rate is pretty normal at like twenty so before we came in i i know that we had you do an x-ray and i'm sure that that was a bit more painful because we had to do so many manipulations but i do wan na note that you are positive for what we call a colles' fracture what that means is that the joints between your wrist like the bones between your wrist that there there is evidence of a a fracture and we are gon na have to treat it a little conservatively at first and then consider some of the options options that are available to us so for your primary diagnosis of a colles' fracture we are going to give you a thumb spica for today and that's going to
[patient] i'm sorry
[doctor] pardon what
[patient] a what
[doctor] we're gon na brace you we're gon na give you a brace
[patient] okay thank you
[doctor] sorry no problem sorry yeah not a thumb spica we're gon na brace your arm and you're gon na have that we we have a couple of options but i think the best course of action is gon na be for surgery we will in the meantime give you pain medication i wan na put you on fifty milligrams of ultram every six hours and then i also wan na get you on get you into physical therapy a few weeks after surgery this is gon na be just a normal procedure you will be in for an overnight stay but after that once we assess and make sure that everything is good you'll be able to go home okay
[patient] when do i have to have the surgery
[doctor] we would like it to happen as quickly as possible you know your body is a wonderful miracle and it's going to start trying to heal on it's own what we need to do is get your wrist straight and then like put screws in to make sure that we hold it in place or else it could like heal and malform
[patient] okay
[doctor] alright so what
[patient] how how long do i have to wear that brace
[doctor] you're gon na be wearing the brace for about six weeks
[patient] six weeks
[doctor] yeah so you're gon na you're gon na come in for your surgery we're gon na perform it you're gon na stay overnight and then you'll be bracing it for six weeks in the meantime you'll also then go to physical therapy i want you there like we're gon na they're gon na do an assessment and determine how much but i'm thinking probably three times a week just to make sure that you can get your wrist as strong as possible to prevent like future injury now the cool thing about getting any kind of a bone break is that your your body comes out even stronger so this should n't happen again but unfortunately like it's these situations that oof that just kind of
[patient] oof
[doctor] these these deform these deformities that really that really kind of hurt is the short version alright no problem any other questions
[patient] no well i am going on vacation do i need to cancel it like can i still go even with the i mean after the surgery
[doctor] yeah
[patient] do it as soon as possible i'm going a vacation in a month so
[doctor] okay how long is the vacation
[patient] it's only for like a couple weeks
[doctor] okay well so you might have to postpone it just because depending on what physical therapy says right if they feel that you can sustain if you can like sustain the exercises while you're gone that if there's something that you can do by yourself then you should be fine but we do wan na give it you said that it's gon na happen in a couple of weeks
[patient] no vacation in a month
[doctor] okay okay yeah so how about in a month we come you come back let's do a checkup again see where we are at and then we can assess whether or not this is something that i would recommend you do
[patient] that sounds good thank you
[doctor] no problem bye
[patient] bye
[doctor] the fracture appears extra-articular and usually proximal to the radial ulnar joint dorsal angulation of the distal fracture fragment is present to a variable degree if dorsal angulation is severe presenting with a dinner fork deformity ulnar styloid fracture is present | CHIEF COMPLAINT
Right wrist injury.
HISTORY OF PRESENT ILLNESS
Diana Scott is a pleasant 61-year-old female who presents to the clinic today for the evaluation of a right wrist injury. The patient sustained this injury yesterday morning, 05/12/2022, when she slipped on the stairs while carrying a laundry basket. She states she tried to catch herself with her arms outstretched. The patient reports an immediate onset of pain and swelling in her right wrist. She denies any previous injuries to her right arm. The patient rates her pain level as a 9/10. Her pain is aggravated by movement. The patient also reports numbness and tingling in her fingers. She has been icing and wrapping her right wrist with an ACE wrap. The patient has also been taking ibuprofen, which provides some relief. She notes fully extending her arm while resting it on a pillow alleviates some of her pain as well.
The patient is going on vacation in 1 month.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right wrist pain and swelling.
Neurological: Reports numbness and tingling to the digits of the right hand.
VITALS
Blood Pressure: Elevated at 140/70 mmHg.
Heart Rate: 80 beats per minute.
Respiratory Rate: 20 breaths per minute.
Body Temperature: 97.2 degrees F.
HEAD: Normocephalic
NECK: No swelling noted
CV: No bilateral lower extremity edema. No carotid bruit. No murmurs, gallops or rubs heard during auscultation of the heart. Palpabale pulses to the bilateral lower extremities.
RESPIRATORY: Normal respiratory effort no respiratory distress. Lungs clear to auscultation bilaterally.
GI/GU: Non-distended
BACK: No evidence of trauma or deformity
NECK: No adenopathy. No thyromegaly.
MSK: Examination of the right wrist: Limited range of movement. Tenderness to palpation. Pain on flexion and extension. Pain with radial deviation and lateral deviation. Pain with wrist abduction and adduction. The metacarpals are intact. Obvious swelling and bruising. Tenderness on palpation throughout. There is evidence of potential fracture feeling and bony crepitus.
RESULTS
X-rays of the right wrist were taken today. These reveal the fracture appears extra-articular and proximal to the radioulnar joint. Dorsal angulation of the distal fracture fragment is present to a variable degree. Dorsal angulation is severe, presenting with a dinner fork deformity. An ulnar styloid fracture is present.
ASSESSMENT
Right wrist Colles fracture.
PLAN
After reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays revealed a right wrist Colles fracture. We discussed treatment options and I have recommended that we proceed with a right wrist ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I explained that we should schedule the operation for as soon as possible to ensure adequate healing and to limit malformation of the wrist. I advised that this procedure will require her to be admitted to the hospital for an overnight stay.
In the meantime, the patient will be placed in a thumb spica brace and receive instructions on its proper usage. I have prescribed the patient Ultram 50 mg every 6 hours to treat her pain. We also discussed that her postoperative course will include wearing a brace for 6 weeks. A few weeks after surgery, the patient will initiate formal physical therapy and will attend 3 times per week to strengthen her right wrist. The patient has a 2-week vacation planned in 1 month. I recommended that we consult with her physical therapist to determine if there are exercises she can perform on her own instead of postponing her vacation.
INSTRUCTIONS
The patient will follow up with me in 4 weeks status post surgery to discuss her progress.
|
D2N078 | aci | [doctor] hey philip good to see you today so take a look here at my notes i see you're coming in for some right knee pain and you have a past medical history of hypertension and we will take a look at that so can you tell me what happened to your knee
[patient] yeah i was you know i was just doing some work on my property and i i accidentally slipped and fell down and i just still having some knee issues
[doctor] okay well that that's not good do you
[patient] no
[doctor] what part of your knee would you say hurts
[patient] i would just say you know the it it you know it basically when i when i'm flexing my knee when i'm moving it up and down and i put pressure on it
[doctor] alright did you hear a pop or anything like that
[patient] i did feel something pop yes
[doctor] okay and did it was it swollen afterwards or is it looks a little bit swollen right now
[patient] yeah little bit swollen yeah
[doctor] okay so so far have you taken anything for the pain
[patient] just taking some ibuprofen just for some swelling
[doctor] okay that's it what would you say your pain score is a out of ten with ten being the worst pain you ever felt
[patient] i would say that when i'm stationary i do n't really feel a lot of pain but if i start doing some mobility i would say probably a four five
[doctor] about a four okay and how long ago did you say this was is this happened this injury
[patient] it's been a week now
[doctor] a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly
[patient] yes i have
[doctor] okay so you might have a little white coat syndrome i know some of my patients definitely do have that so what about your diet i know we talked a little bit before about you reducing your sodium intake to about twenty three hundred milligrams per per day i know you were during the pandemic your diet got out of little bit out of control so how have you been doing how have you been doing with that
[patient] i definitely need some help there i have not have not made some some changes
[doctor] okay yeah we definitely need to get you to lower that salt intake get your diet a little bit better because the hope is to get you off that medication and get your blood pressure to a manageable level okay so we yeah we definitely can talk about that alright so lem me take a look at your knee i'll do a quick physical exam on you and before i do just want to make sure you're not having any chest pain today
[patient] no
[doctor] are you any belly pain
[patient] no
[doctor] no shortness of breath just wan na make sure
[patient] no
[doctor] okay so i'm just gon na listen to your lungs here your lungs are clear bilaterally i do n't hear any wheezes or crackles listen to your heart so on your heart exam i do still hear that grade two out of six systolic ejection murmur and you already had that and so we we knew about that already so lem me look at your knee here so when i press here on the inside of your knee does that hurt
[patient] a little bit
[doctor] little bit how about when i press on the outs the outside gon na press on the outside is that painful
[patient] no
[doctor] no alright so i'm gon na have you flex your knee is that painful
[patient] yeah that's uncomfortable
[doctor] that's uncomfortable and extend it so that's painful
[patient] yeah yes
[doctor] okay so on your knee exam i i see that you do have pain to palpation of the medial aspect of your right knee you have some pain with flexion extension i also identify some edema around the knee and some effusion you have a little bit of fluid in there as well so prior to coming in we did do an x-ray of that right knee and luckily you did n't break anything so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you have what we call a mcl strain so a medial collateral ligament strain so when you fell i think you twisted a little bit and so it irritated you strained that that ligament there so for that what we can do for you first i'm gon na prescribe you some ibuprofen eight hundred milligrams and you can take that twice a day and that's gon na help you with that swelling and that pain that you currently do have i'm also gon na put you in a a knee brace just to try and support those muscles to allow it to heal and then i want you to ice the knee you can do that for twenty minutes at a time for three to four times a day that should also help with the the swelling of your knee for your hypertension now i'm gon na keep you on that twenty of lisinopril okay because you are taking it and you you're doing pretty good with it i also want to get you a referral to nutrition just to try to help you with that diet you know because right now you are your diet is little bit out of control so we just need to rain you in a little bit and hopefully you know with their help we can eventually get you off that lisinopril alright so do you have any questions for me
[patient] do i need to elevate my leg or stay off my leg or
[doctor] yeah i would yeah you can elevate your leg stay off your stay off your leg you know if you have any kids have them work out in the yard instead of you just to to for a couple of weeks it's a good thing if you want to do that
[patient] tell him this doctor's order
[doctor] tell definitely tell him his doctor tell him i said it
[patient] alright do you have any other questions no that's it i appreciate you seeing me
[doctor] alright so my nurse will be in with the those orders and we will see you next time | CHIEF COMPLAINT
Right knee pain.
REVIEW OF SYSTEMS
Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Gastrointestinal: Denies abdominal pain.
Musculoskeletal: Reports right knee pain.
PHYSICAL EXAM
Respiratory
- Auscultation of Lungs: Clear bilaterally. No wheezes.
Cardiovascular
- Auscultation of Heart: Grade 2/6 systolic ejection murmur. Some edema and effusion noted around the right knee.
Musculoskeletal
- Examination: Right knee
- Palpation: Pain to palpation of the medial aspect. No pain to palpation of the lateral aspect.
- ROM: Pain with flexion and extension.
-Some effusion noted around the right knee.
RESULTS
X-rays of the right knee were taken. These show no fractures or bony abnormalities.
ASSESSMENT AND PLAN
1. Right knee MCL strain.
- Medical Reasoning: Based on the physical examination findings, the patient has a MCL strain of the right knee. - Medical Treatment: I have prescribed ibuprofen 800 mg twice a day. I will also place him in a knee brace. I advised him to ice the knee for 20 minutes at a time for 3 to 4 times a day. The patient was instructed to elevate his leg as needed and avoid strenuous activities for 2-3 weeks.
2. Hypertension.
- Medical Treatment: The patient will continue lisinopril 20 mg daily. I have also provided a referral to see a nutritionist for dietary changes.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N079 | aci | [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 | CHIEF COMPLAINT
Left shoulder pain.
HISTORY OF PRESENT ILLNESS
Wayne Taylor is a pleasant 66-year-old male who presents to the clinic today for the evaluation of left shoulder pain. The onset of his pain began 3 weeks ago. He denies any specific injury. The patient states he is active and has been renovating his basement. He reports a history of intermittent aches and pains in his left shoulder. He has difficulty reaching for or lifting any objects. He adds that he avoids reaching overhead secondary to the pain. The patient describes his pain as constant and worsening. He notes his pain is unbearable when lying on his left shoulder at night. He denies any numbness or tingling in the bilateral upper extremities. He has been taking 2 Extra Strength Tylenol every 6 to 8 hours, which provides some relief.
REVIEW OF SYSTEMS
Musculoskeletal: Reports left shoulder pain. Neurological: Denies numbness or tingling in the bilateral upper extremities.
VITALS
All vital signs are within the normal limits.
PHYSICAL EXAM
Capillary refill is less than 3 seconds.
NEURO: Normal sensation. Sensation is intact to light touch in the left upper extremity.
MSK: Examination of the left shoulder: Limited active and passive ROM. Tenderness over the greater tuberosity of the humerus. No tenderness at the sternoclavicular or acromioclavicular joints. Good hand grip.
RESULTS
X-rays of the left shoulder were obtained and are reviewed today. These reveal there are no fractures.
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.
INSTRUCTIONS
The patient will follow up with me after he has completed his course of physical therapy. |
D2N080 | aci | [doctor] okay hi andrea well i
[patient] hello
[doctor] i understand you're you've come in with some right knee pain can you tell me about it what's going on
[patient] it it's not the right knee it's the left knee
[doctor] okay the left knee
[patient] and it just happens occasionally less than once a day when i'm walking all of a sudden it is kind of like gives out and i think here i'm going to fall but i usually catch myself so lot of times i have to hold a grocery cart and that helps a lot so it comes and goes and it it passes just about as quickly as it comes i do n't know what it is whether i stepped wrong or i just do n't know
[doctor] okay well so where does it hurt like in on the inside or the outside or
[patient] internally and it it just the whole kneecap fades
[doctor] okay well did you hear or feel a pop at any point
[patient] no
[doctor] okay
[patient] like that
[doctor] have you ever had any type of injury to that knee i mean did you fall or bump it against something or
[patient] no not that i can recall
[doctor] okay and have is it painful have you taken anything for for pain
[patient] no because it does n't last that long
[doctor] okay
[patient] it just like i said it just it goes about as fast as i came in
[doctor] so is it interfering with your just things you like to do and
[patient] hmmm no not really
[doctor] so i know you said that you like to do a lot of travel
[patient] yeah i've got a trip planned here in the next month or so and we are going down to columbus georgia to a a lion's club function and probably be doing a lot of walking there and they got some line dances planned and i do n't think i will be able to participate in that because of the knee
[doctor] is that where you would be kicking your leg out or something
[patient] no it's do n't you know what line dancing is like dancing in theories of fairly fast moves but it's mostly sideways motion
[doctor] and is and that you think that's when your knee might give out then or just not gon na take the chance
[patient] not gon na take the chance
[doctor] okay yeah that sounds like a good idea have you thought about even having a a cane just in case or do you think that's does that happen often enough
[patient] wrap it i would n't be able to keep track of it so no no pain
[doctor] okay okay well so since you're in how about your blood pressure how how is it doing and have you been taking your blood pressures at home like we talked about
[patient] yes they are doing fine still about the same
[doctor] so
[patient] correct that whatever
[doctor] so what has it been running
[patient] i ca n't really remember it's been several days since i took it but i think it runs around one twenty over seventy somewhere along in there
[doctor] okay alright and so what about your medication we have you on some medication for your blood pressure right
[patient] yes i take take them regularly at eight thirty in the morning and eight thirty at night
[doctor] and what is the medication and the dosage that you are taking
[patient] i'm taking a farxiga and amlodipine
[doctor] okay
[patient] and lisinopril and the hydrochlorothiazide so i i ca n't pronounce that one so but those are all small dosage pills
[doctor] that but yeah go ahead
[patient] no that was it i just take them regularly eight thirty in the morning eight thirty at night
[doctor] yeah well that's good i i know you said you set an alarm on your phone to make sure that you get them taken at the right time so that's really good and how are your blood sugars doing how is your diet doing
[patient] my blood sugar has been running a little higher at about one thirty
[doctor] is that in the morning when you're fasting
[patient] yes
[doctor] okay
[patient] and i have been told that sometimes the morning blood sugars are higher for some reason but i do n't know i i do n't really worry about it as long as it does n't get up too extremely high so
[doctor] and are you taking your metformin
[patient] yes yes that's along with the blood pressure medicine morning and night
[doctor] okay alright so are you are you eating like late at night or anything like that
[patient] no we usually eat by six
[doctor] okay okay alright well hopefully we can get you to feeling better okay so i want to do a quick physical exam really check that knee out so your vital signs look good they they look alright your temperature is ninety eight . two your pulse is seventy two respirations are sixteen blood pressure is one twenty two over seventy so that looks fine i'm gon na go ahead and take a listen to your heart and lungs so on your heart exam it's a nice regular rate and rhythm but i appreciate a slight two over six systolic ejection murmur at the left base here on your lung exam your lungs are clear to auscultation bilaterally okay now let's take a quick look at that knee so does it hurt when i press on it
[patient] no
[doctor] okay can you bend your knee and straighten it out
[patient] yes
[doctor] okay i'm gon na do some maneuvers and i'm gon na just gon na call out my findings on this okay on your right knee exam no ecchymosis or edema no effusion no pain to palpation of the of the left medial knee is there any decreased range of motion do you feel you feel like you're you're able to fully move that as you should the same as the other knee
[patient] yeah
[doctor] okay so no decreased range of motion negative varus and valgus test okay and so with your x-rays i reviewed the result of your left knee x-ray which showed no evidence of fracture or bony abnormality so lem me tell you a little bit about my plan so your left knee pain i think you just have some arthritis in that i want to prescribe some meloxicam fifteen milligrams a day we might do some physical therapy for that just to strengthen the muscles around that area and prevent any further problems with that okay and so for your second problem the hypertension so i wan na continue the lisinopril at twenty milligrams a day and order an echocardiogram just to evaluate that heart murmur alright and
[patient] okay
[doctor] for the diabetes mellitus i wan na order a hemoglobin a1c to see if we need to make any adjustments to your metformin and i'm also gon na order a lipid panel okay do you have any questions
[patient] no i do n't think so when will all this take place
[doctor] we will get you scheduled for the echocardiogram i will have my nurse come in and we will get that set up okay | CHIEF COMPLAINT
Left knee pain.
HISTORY OF PRESENT ILLNESS
Andrea Barnes is a 34-year-old female who presents today for evaluation of left knee pain.
The patient has been experiencing intermittent episodes of pain and sudden instability with ambulation. Her pain is localized deep in her patella and occurs less than once daily. Due to the fleeting nature of these episodes, she has not taken medication and simply braces herself until it passes. She denies any trauma or injury, or ever hearing or feeling a pop in the knee. Her symptoms do not interfere with her daily activities and she does not use a cane.
Regarding her hypertension, it has been several days since she last checked her blood pressure at home, but it was approximately 120/70 mmHg at that time. Her current medications include amlodipine, lisinopril, and hydrochlorothiazide, all of which she takes on a regular basis.
In terms of her diabetes, her fasting morning blood glucose levels have been approximately 130 based on home monitoring. This is slightly higher than usual, even though she has been compliant with metformin and Farxiga. She does try to avoid eating late at night.
MEDICAL HISTORY
Patient reports a personal history of hypertension and type 2 diabetes.
SOCIAL HISTORY
Patient likes to travel and is planning a trip to Columbus, Georgia in the next month or so. She is part of the Lion's Club.
MEDICATIONS
Patient reports that she is taking amlodipine, lisinopril 20 mg once daily, hydrochlorothiazide, Metformin, and Farxiga.
REVIEW OF SYSTEMS
Musculoskeletal: Reports left knee pain and instability,
VITALS
Temperature: 98.2 degrees F
Heart rate: 72 bpm
Respirations: 16
Blood pressure: 122/70 mmHg
PHYSICAL EXAM
MSK: Examination of the right knee: No ecchymosis or edema. No effusion. No pain with palpation.
Examination of the left knee: Full range of motion. Negative varus and valgus stress test.
RESULTS
X-rays were obtained and reviewed today. These reveal no evidence of fracture or bony abnormality.
ASSESSMENT
1. Left knee pain.
2. Hypertension.
3. Diabetes mellitus type 2.
PLAN
After reviewing the patients x-rays, I believe there is some arthritis in the knee. I'm going to prescribe meloxicam 15 mg once daily. We can consider physical therapy to strengthen the muscles around the area to prevent any further issues.
Her hypertension is well controlled with her current medication regimen. She can continue with lisinopril 20 mg once daily. I'm also going to order an echocardiogram for further evaluation of the murmur heard on exam.
She has been compliant with metformin as prescribed, but her blood glucose levels have been slightly elevated recently. I'm going to order a lipid panel, as well as a hemoglobin A1c to determine if any adjustments need to be made to her dose of metformin. |
D2N081 | aci | [doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three nonsmile cell lung cancer who presents for follow-up during neo agit chemotherapy she was diagnosed with a four . four centimeter left upper lobe nodule biopsy was positive for adenocarcinoma molecular testing is pending at this time alright hello beverly how are you
[patient] i'm good today
[doctor] you're good today yeah you've been going through a lot lately i know you just had your treatment how how are your symptoms
[patient] my symptoms are pretty good today i just kind of have a minimal cough and a sore throat
[doctor] okay
[patient] but that's all i'm feeling today
[doctor] okay and how about fatigue have you been feeling more tired
[patient] yes a little bit
[doctor] okay and how about any nausea or vomiting
[patient] no not as of today
[doctor] okay and i know you were mentioning a cough before how is it as far as walking are you having any shortness of breath
[patient] i have n't noticed any shortness of breath it just kind of seems to be a lingering kind of light dry cough
[doctor] cough okay is it any mucus with it or is it a dry cough
[patient] more dry
[doctor] a dry cough okay and tell me more about this sore throat
[patient] this kind of seems to be persistent comes and goes it will be worse sometimes and then others it feels better trying to drink lots of fluids
[doctor] okay
[patient] to see if it can it you know the dry coughing if it's part of that or what i can do
[doctor] okay and when you mention drinking and eating is do you feel like anything is getting stuck there
[patient] no i do n't feel like anything is getting stuck right now and i have n't been i have been eating but not as much as i normally would
[doctor] okay okay alright and how are you doing as far as like just emotionally and mentally how are you doing i'm just talking a little bit about your support systems
[patient] the nursing staff and the office has been very good to help you know with anything that i need as far as support so just since we are just getting started so far on the journey i do feel like i have support and mentally you know still feel strong
[doctor] okay and how about with family or friends have you been able to turn to anyone
[patient] i do have good family members that have been supportive and they have come to my treatment with me
[doctor] okay excellent excellent and so right now you're on a combination of two different chemotherapies the cisplestan as well as the eupside and you had your last treatment just a few days ago but you're saying right now you've been able to tolerate the nausea and the fatigue
[patient] yes i have n't had any nausea but you know just slight fatigue it does n't seem to be overwhelming
[doctor] okay okay so we are gon na go ahead if it's okay with you and start your physical exam reviewing your vitals so vitals look good especially your oxygen especially with the chemotherapy you've been getting and the cough so your oxygen looks good so i'm happy with that so now i'm just examining your neck especially with your sore throat and i do n't appreciate any cervical lymphadenopathy and also no supraclavicular adenopathy listening to your heart you have a nice regular rate and rhythm with no murmurs that i appreciate now on your lung exam when you're taking some deep breaths i do notice some crackles in your lungs bilaterally and what that means is there is there is some faint sounds that i'm hearing which could represent some fluid there so on looking at your skin exam on your chest you do have some erythema on the anterior side of the chest on the left side and this could be related to the radiation so on your lower extremities i appreciate no edema and everything else looks good and thank you i know you did a chest x-ray before coming in so on your results for the chest x-ray it does look like you have some mild radiation pneumonitis which basically means some inflammation of the lungs most likely due to the radiation so what does this all mean so for your assessment and plan so for the first diagnosis the first problem of the lung cancer so what we're gon na do is we're gon na continue with the current regimen of your chemotherapy of the cisplacin and the etoside and we're gon na continue with your current dose of radiation at forty five grade and when that's complete we will repeat some imaging and hopefully you know the tumor will shrink down enough that we can remove it surgically okay for problem number two so the radiation pneumonitis so that's what causing that cough as well as some of the shortness of breath i know you're not experiencing it much now so what i'm gon na do for that is actually gon na prescribe you a low dose of prednisone and so that's an will help with the inflammation i'm gon na give you forty milligrams daily for five days and so hopefully that will help reduce the inflammation and so that you can continue with the radiation okay how does that sound so far
[patient] that sounds great thank you
[doctor] okay and then lastly for the painful swallowing that you're having so the inflammation you're having it not only in your lungs but it also in your esophagus as well so what i'm gon na do is prescribe you you're taking the the prednisone i'm also gon na give you a lidocaine swish and swallow and you can do that four times a day and so that will be able to help you so you can eat immediately after taking it and it can also help so that you can continue to take food and fluids prevent dehydration and any further weight loss
[patient] great
[doctor] okay any questions for me
[patient] i do n't believe so at this time
[doctor] okay alright so i'll see you at your next visit
[patient] great thank you
[doctor] you're welcome and so now just | CHIEF COMPLAINT
Follow up of stage III non-small cell lung cancer.
MEDICAL HISTORY
Patient reports history of stage III non-small cell lung cancer.
SOCIAL HISTORY
Patient reports having a good family support system and that some of her family has accompanied her to her chemotherapy sessions.
MEDICATIONS
Patient reports she is currently receiving chemotherapy treatment consisting of Cisplatin and etoposide.
REVIEW OF SYSTEMS
Constitutional: Reports fatigue and decrease in appetite.
HENT: Reports sore throat. Denies dysphagia.
Respiratory: Reports dry cough. Denies shortness of breath.
Gastrointestinal: Denies nausea or vomiting
VITALS
Vitals are within normal limits including oxygen saturation.
PHYSICAL EXAM
Neck
No cervical lymphadenopathy or supraclavicular adenopathy.
Respiratory
- Auscultation of Lungs: Crackles heard bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs.
Musculoskeletal
- Examination: No edema.
Integumentary
- Erythema noted on the anterior side of the chest on the left side possibly related to radiation.
Hematology/Lymphatic/Immunology
- Palpation: No enlarged lymph nodes.
RESULTS
Chest x-ray is reviewed and demonstrates mild radiation pneumonitis.
ASSESSMENT AND PLAN
1. Stage III non-small cell lung cancer.
- Medical Reasoning: The patient has a recent diagnosis of stage III non-small cell lung cancer. Biopsy was positive for adenocarcinoma. Molecular testing is pending at this time.
- Medical Treatment: We are going to continue with the current regimen of combination chemotherapy consisting of Cisplatin and etoposide. We are also going to continue with her current dose of radiation at 45 Gy. Once this is complete, we will obtain repeat imaging in hopes that the tumor will decrease in size enough for surgical removal.
2. Radiation pneumonitis.
- Medical Reasoning: The patient is experiencing a persistent dry cough. Recent x-rays are reviewed and demonstrated evidence of mild radiation pneumonitis.
- Patient Education and Counseling: We discussed the etiology of her dry cough is from her mild radiation pneumonitis.
- Medical Treatment: A prescription of prednisone 40 mg daily for 5 days is provided to help with her inflammation.
3. Painful swallowing.
- Medical Reasoning: The patient is experiencing painful swallowing secondary to inflammation of the esophagus.
- Patient Education and Counseling: We discussed the etiology of her painful swallowing and that a lidocaine viscous solution will be beneficial in preventing dehydration and any further weight loss.
- Medical Treatment: A lidocaine viscous solution was provided to be performed 4 times daily.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will return to clinic at her next scheduled follow up. |
D2N082 | aci | [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 | HISTORY OF PRESENT ILLNESS
Kyle Lee is a pleasant 46-year-old male who presents to the clinic today for evaluation of low immunoglobulin A level. He was referred to our offices by his primary care physician after routine labs revealed abnormalities. The patient states he has been experiencing frequent infections. During the winter months, he experiences frequent colds that tend to linger, however this is not uncommon for him. The patient denies abdominal issues or diarrhea.
The patient was recently diagnosed with type 2 diabetes. He is currently taking metformin.
MEDICAL HISTORY
Patient denies a history of blood transfusions.
SOCIAL HISTORY
He recently traveled internationally on a trip to Zambia. His family owns a local doughnut shop.
FAMILY HISTORY
Patient denies a family history of immune deficiencies.
REVIEW OF SYSTEMS
Gastrointestinal: Denies abdominal issues or diarrhea.
VITALS
Temperature: Normal.
All other vitals were reviewed and are within normal limits.
PHYSICAL EXAM
NECK: No swelling noted. No lymphadenopathy.
CV: Normal heart rhythm with no murmurs.
RESPIRATORY: Lungs are clear. There's no wheezes, rales, or rhonchi.
Gastrointestinal: Abdomen is soft and without tenderness.
RESULTS
I did review the results of her recent lab work. It is consistent as her primary care physician noted with an IgA deficiency.
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. |
D2N083 | aci | [doctor] hey lawrence how're you doing
[patient] i'm doing alright aside from this elbow pain
[doctor] so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain
[patient] so i really during this pandemic i really got into ceramics and doing pottery so i've been doing a lot of pottery and over the past week i then started to develop this elbow pain
[doctor] okay and then so tell me a little bit more about that elbow pain where does it hurt exactly
[patient] you know it hurts a lot in the inside of my elbow
[doctor] okay so the inside of your right elbow okay
[patient] yeah
[doctor] and then does the pain radiate down your arm or up into your shoulder or anything like that
[patient] it does n't go into my shoulder it's it stays mostly at my elbow but it can go down a bit into my forearm
[doctor] okay and then do you remember any trauma did you hit your arm or elbow or any on anything
[patient] no nothing i i really was trying to think if there is anything else and i ca n't think of anything
[doctor] okay and you've never injured that right elbow before
[patient] no
[doctor] alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life
[patient] i would say probably a six
[doctor] okay and does that pain keep you up at night
[patient] it does
[doctor] okay and when you have that kind of pain does it keep you from doing other type of activities
[patient] yeah i mean i still try to like work through with using my arm but yeah it's it's it's difficult for me sometimes to lift and do things because of that pain
[doctor] okay and then and how long has this pain been going on
[patient] about four days now
[doctor] alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief
[patient] i've tried ibuprofen that helps a little but not much
[doctor] okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here
[patient] yes i do
[doctor] okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that
[patient] not really
[doctor] okay now turn your wrist in so do you have any pain when you do that
[patient] yeah that hurts
[doctor] okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist
[patient] yes i do
[doctor] alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend
[doctor] that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay
[patient] alrighty
[doctor] alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week
[patient] alright thank you
[doctor] thank you | CHIEF COMPLAINT
Right elbow pain.
HISTORY OF PRESENT ILLNESS
Lawrence Butler is a pleasant 45-year-old male who presents to the clinic today for the evaluation of right elbow pain.
Over the past week, the patient has developed 6/10 pain in the "inside" of his right elbow. The pain may radiate into his forearm on occasion, but does not extend up to his shoulder. He denies any history of trauma or injury, but he did start making pottery during the COVID-19 pandemic and suspects that his symptoms could be related to that. His symptoms affect his ability to lift objects or perform his typical activities of daily living. Ibuprofen provides minimal symptomatic relief.
SOCIAL HISTORY
The patient reports that he began making pottery during the COVID-19 pandemic.
MEDICATIONS
The patient reports that he has been taking ibuprofen.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right elbow pain.
VITALS
Normal
PHYSICAL EXAM
MSK: Examination of the right elbow: Moderate tenderness at the medial epicondyle. No pain with supination of the forearm. Pain with pronation of the forearm. Pain with resistance against flexion of the wrist.
RESULTS
X-ray imaging of the right elbow was obtained and reviewed in office today. These reveal no evidence of fracture or bony abnormality.
ASSESSMENT
Right medial epicondylitis.
PLAN
The patient and I discussed his diagnosis in detail, and I explained that his symptoms are likely caused by overuse and potential damage of the tendons. We will provide him with sling to be worn during the day while he is awake. I want him to take ibuprofen 600 mg every 6 hours with food for a full week and ice the elbow for 20 minutes, 3 times daily. Finally, I advised the patient to rest his elbow and avoid doing any pottery for the next couple of weeks.
INSTRUCTIONS
The patient will follow up in 1 week. |
D2N084 | aci | [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 | CHIEF COMPLAINT
Follow up.
SOCIAL HISTORY
The patient has been trying to limit his tobacco use for 2 years. He reports smoking once every week.
MEDICATIONS
Bumex 2 mg once daily.
Cozaar 100 mg daily.
Norvasc 5 mg once daily.
REVIEW OF SYSTEMS
Constitutional: Denies problems sleeping.
Cardiovascular: Reports chest pain.
Respiratory: Reports shortness of breath.
Musculoskeletal: Reports bilateral ankle swelling.
VITALS
Blood pressure is 128/72 mm Hg. Other vital signs are within normal limits.
PHYSICAL EXAM
Neck
- General Examination: No JVD
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: 2/6 stable systolic ejection murmur
Musculoskeletal
- Examination: Lower extremities show trace edema.
RESULTS
An echocardiogram, obtained at an outside facility, was reviewed today. It demonstrates a preserved ejection fraction of 55%. Normal diastolic filling. Mild to moderate mitral regurgitation.
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.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient was instructed to call me if he gains 3 pounds in 2 days. |
D2N085 | aci | [doctor] hi russell how are you what's been going on
[patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days
[doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee
[patient] yeah it kinda burns a little bit
[doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay
[patient] okay
[doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you | CHIEF COMPLAINT
Right-sided abdominal pain
MEDICAL HISTORY
Patient reports history of kidney stones.
FAMILY HISTORY
Patient reports his father has a history of kidney stones.
MEDICATIONS
Patient reports use of Tylenol.
REVIEW OF SYSTEMS
Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting
Genitourinary: Reports dysuria and dark colored urine. Denies hematuria.
PHYSICAL EXAM
Gastrointestinal
- Examination of Abdomen: No masses or tenderness to palpation. No rebound or guarding. No peritoneal signs. Positive CVA tenderness on the right flank.
RESULTS
Previous CT scan of the abdomen ordered by the patient's PCP is reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter. There is no evidence of hydronephrosis.
ASSESSMENT AND PLAN
1. Acute nephrolithiasis.
- Medical Reasoning: The patient presents with complaints of right-sided abdominal pain. His previous CT scan was reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter without evidence of hydronephrosis.
- Medical Treatment: I have recommended that he push fluids in order to help facilitate urination to help pass the stone. He will be provided with a strainer to allow us to potentially test the stone if he is able to pass it. I have also prescribed oxycodone 5 mg every 6 to 8 hours as needed for pain. He can continue to alternate oxycodone with Tylenol. A basic metabolic panel, urinalysis, and urine culture will also be ordered.
INSTRUCTIONS
He will follow up in 1 to 2 weeks. If he is still having symptoms at that time, we will discuss further treatment such as lithotripsy or ureteroscopy. He is to contact me if he is having worsening symptoms over the next week. |
D2N086 | aci | [doctor] hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that
[patient] yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some burning and some stinging and looked down and saw a blister i did n't think too much of it because it was on the pad of the bottom of my foot around my heel and i just had been walking on the front part of my foot i started to notice a foul smell and my wife mentioned something to me the other day and i noticed my dog was also smelling my socks a lot and so we looked and saw that the blister had become unroofed or the the top part of the skin of the blister became undone and then underneath it was just this really thick soft mushy skin that had a bad smell with some yellow drainage and so and barbara called the primary care doctor who then got me in to see you he started me on some antibiotics about six days ago and i never had any nausea or vomiting but my wife checked my temperature it was about ninety nine point seven and then at one point i had to put on an extra blanket in bed because i had some chills and when i started the antibiotics it started to feel pretty good but we've now noticed that it has turned black around the outside of the wound and i'm getting some cramping in my calf muscle as well and so there was a red streak also that was coming up the front part of my my ankle along the inside portion of my calf muscle and it's super super hot and so they wanted me to take a have have you look at it
[doctor] okay thank you for sharing that history with me and did you complete that course of antibiotics
[patient] i think he called in ten days' worth and i'm on day six or seven right now i know i've got about two or three days left
[doctor] okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now
[patient] yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point
[doctor] okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that
[patient] yeah my my a1c is six point seven it's pretty well controlled
[doctor] okay
[patient] i used to be on an insulin pump and i had an a1c that at one point was like thirteen but we worked with an endocrinologist to get it down to where it's at now i've been six point seven for probably two years now and i rarely have a blood sugar that goes over two hundred i check two or three times a day if i feel weird i'll check it again but i noticed my sugars have probably been trending in the three to four hundreds the last two weeks and then i had one spike at one point at like five or six hundred that got our attention and i think that's also what made my wife call the primary care doc
[doctor] okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park
[patient] yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now
[doctor] absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there
[patient] i do n't feel that right there
[doctor] okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure
[patient] no not really so you're gon na continue the antibiotics that i'm on and possibly extend or call in a new antibiotic depending on the culture
[doctor] correct
[patient] if i heard
[doctor] yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy
[patient] okay sounds good
[doctor] alright | CHIEF COMPLAINT
Non-healing ulcer on his right foot.
HISTORY OF PRESENT ILLNESS
Nicholas Gutierrez is a pleasant 45-year-old male who presents to the clinic today for the evaluation of a non-healing ulcer on his right foot. The patient was referred from his primary care physician. The onset of his pain began 6 weeks ago, after wearing a pair of shoes that were too tight.
Today, he describes a burning, stinging, and throbbing sensation. The patient reports a blister on the pad of the plantar aspect of his foot around his heel. He explains that he has been ambulating on the anterior aspect of his foot. He explains that the top part of the skin of the blister detached, which revealed a thick, soft, mushy skin associated with unpleasant smell and yellow drainage. The patient called his primary care physician, who referred him to our office. He was prescribed a 10-day course of antibiotics approximately 6 days ago. He experienced chills and a fever of 99.7 degrees Fahrenheit. The patient denies any nausea or vomiting. He states that when he started the antibiotics, his foot began to feel pretty good. However, he has now noticed that his foot has turned black around the outside of the wound, and he is experiencing cramping in his calf muscle as well. He also reports a burning red streak that was coming up the front part of his ankle along the inside portion of his calf muscle. While palpating his calf, he has noted stiffness in the muscle that is now up to the patella. The patient reports that he has been coughing a lot over the last 2 days. He has experienced shortness of breath with ambulation around the house. He reports that he purchases new diabetic shoes yearly and changes the inserts every 3 to 4 months.
The patient is diabetic and has diabetic neuropathy. He explains that his blood sugar has been trending in the 300 to 400's over the last 2 weeks. At one point, he had a blood sugar spike to either 500 or 600. He states that his last hemoglobin A1c was 6.7, which has been his average for approximately 2 years. The patient checks his blood sugar 2 to 3 times per day and rarely has a blood sugar that goes over 200. He explains that he used to be on an insulin pump and had an A1c that at one point was 13. He states that he worked with an endocrinologist to get it down to where it is now.
MEDICAL HISTORY
The patient reports a history of diabetic neuropathy.
SOCIAL HISTORY
The patient enjoys hiking.
REVIEW OF SYSTEMS
Constitutional: Reports subjective fever and chills
Respiratory: Reports cough and shortness of breath with ambulation.
Gastrointestinal: Denies nausea and vomiting.
Musculoskeletal: Reports right foot pain and right calf cramping.
Skin: Reports right foot ulcer with yellow foul smelling drainage, and red streaking coming up the front part of his ankle along the inside portion of his calf muscle.
VITALS
Temperature is slightly elevated.
Vitals are otherwise good.
PHYSICAL EXAM
CV: Edema and pain in calf. Bilateral palpable femoral and papiteal pulses are present. I do not recognize a palpable dorsalis pedis or posterior tibial pulse; however, they are present via Doppler.
MSK: Examination of the right foot: The necrotic wound on his heel is present. It is approximately 2 cm x 2 cm. I do recognize the sloughing of the tissue, as well as what looks like cellulitis around the area, and erythema. An odor is present from the wound. I do not appreciate any bony exposure now. No pain to palpation in the effected area.
RESULTS
3 views of the right foot were taken today. These reveal no evidence of osteomyelitis or infection.
ASSESSMENT
Right non-healing diabetic foot ulcer.
Diabetes.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed.
In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results.
INSTRUCTIONS
The patient will follow up with me in 7 days to check on his progress. |
D2N087 | aci | [doctor] hi richard how are you the medical assistant told me that you have a tick bite is that what happened
[patient] i really do n't know where i got it but i i had i do get out in the woods and i do spend a lot of time out in the yard but yeah i've got a tick bite around my knee and and it's been it's been over a week and and just it just burns and just quite annoying
[doctor] okay and have you had any fever or chills
[patient] i have not at this point it just feels warm on that spot
[doctor] okay alright and have you noticed any other joint pain like in your elbows or shoulders or anything like that that since this started
[patient] nothing other than my typical arthritic pain
[doctor] okay alright now you say that you like to go outside and and you're working in the yard now i i heard that you were a a hunter when was the last time you went hunting has hunting season started yet i do n't even know
[patient] well i i did go hunting not long ago couple of weeks ago
[doctor] okay did you did you
[patient] windle season is open well it it's actually on a on a a got the right word for it but it it's where they train dogs and things like that
[doctor] okay
[patient] type thing
[doctor] okay did you i did did did were you able to shoot anything did you bring anything home
[patient] well actually i yeah i shut several i had some grandchildren with me so i let them have what they wanted
[doctor] nice nice you know i i did hear i do n't know much about hunting but i did hear a hunting software joke the other day do you want to hear it
[patient] sure
[doctor] so what software do hunters use for designing and hunting their pray
[patient] man i have no idea
[doctor] the adobee illustrator get it
[patient] do n't be
[doctor] anyway i die grass let's just get back to our visit here so about your line or about your tick bite so do you notice that it's hard for you to move your knee at all
[patient] not at this time no
[doctor] no and do you have any problems walking
[patient] no
[doctor] no okay and have you ever had a tick bite before
[patient] i have when i was younger i used to get a lot of them because i spent a lot of time out of the woods never get into anesthesia takes you can get several bites out of that but this was just one
[doctor] okay alright and have you ever been diagnosed with what we call lyme disease before
[patient] i have not
[doctor] you have not
[patient] i would n't know so i would n't know what symptoms are
[doctor] okay
[patient] what you just asked me i guess maybe
[doctor] yeah so some of those symptoms like any flu like symptoms have you had like any body aches or chills or anything like that
[patient] no just really just kind of a a headache just generally do n't feel well
[doctor] generally do n't feel well okay and has that been since the tick bite
[patient] it has
[doctor] it has okay alright and any other symptoms like a cough or shortness of breath or dizziness or anything like that
[patient] no
[doctor] okay now since you are here let me just ask you a little bit about your high blood pressure did you buy the blood pressure cuff i asked you to have you been checking your blood pressure at home
[patient] periodically yes
[doctor] okay and do you think that they are running okay
[patient] yeah blood pressure seems to be doing okay the lisinopril works well
[doctor] good i was just gon na ask you if you were taking your lisinopril so that's good okay and any side effects from the lisinopril since we started it i think we started it about a year ago two years ago
[patient] no no no side effects that i'm aware of
[doctor] no side effects okay and then in terms of your diabetes are you watching your sugar intake
[patient] yeah i usually watch it the form of high what i'm eating but
[doctor] i am a big pie fan as well i know what's your favorite type of pie
[patient] well you know it's favorite boy i just like pie you know apples cherry chocolate you know bicon
[doctor] yeah
[patient] i try to try to avoid the bicon because i think it's just all sugar but i do like it
[doctor] okay
[patient] less
[doctor] i like it too alright are you taking the metformin twice a day
[patient] not everyday but most of the time
[doctor] okay alright and are you checking your blood sugars pretty regularly
[patient] i try to
[doctor] okay and do you do you know on average how they're running are they running below like one fifty or
[patient] yeah it's definitely running below that
[doctor] okay your blood sugars are running below
[patient] it's it's probably with with with the metformin it seems to be you know one twenty
[doctor] good
[patient] pretty regular
[doctor] good your blood sugars are running in the one twenties that's really good okay alright well i wan na just go ahead and do a quick physical exam okay so i'm looking here at your vital signs and your vital signs look really good i do think you're doing a good job with taking your lisinopril your blood pressure's about one twenty two over seventy right now which is right where we want it your heart rate is nice and slow at sixty seven again which is right where we want it and i do n't appreciate any fever today you you have a normal temperature at ninety eight . four which is really good so i'm just gon na be going ahead and calling out some physical exam findings and i'm gon na let you know what that means when i'm done okay so on your heart exam your heart is in a nice regular rate and rhythm i do n't appreciate any murmur rub or gallop on your lung exam your lungs are nice and clear to auscultation bilaterally on your right knee exam i do appreciate some erythema and edema as well as an area of fluctuance over your right patella now does it hurt when i press
[patient] it's a little bit sore
[doctor] okay there is pain to palpation of the right anterior knee and i'm just gon na bend your knee up and down does that hurt at all
[patient] no no it's just more of the typical grinding that i would feel
[doctor] okay there is full range of motion of the right knee and on skin examination there is evidence of a bull's-eye rash over the right knee okay so what does that mean richard so that means that you know you do have some area of some inflammation over the over the right knee where you where you have that tick bite and you do have what we call that bull's eye rash which is what we get concerned about with with lyme disease so let's just talk a little bit about you know my assessment and my plan for you okay so for this first problem of your of your tick bite my concern is that you might have lyme disease based on the presentation of your right knee so i'm gon na go ahead and start you on doxycycline one hundred milligrams twice a day
[patient] we're gon na continue that for about three weeks i'm also gon na go ahead and send a lyme titer as well as a western blot to see if you do in fact have lyme lyme disease and we'll have to go ahead and just see how you do with this we you know i'd like to avoid intravenous antibiotics which i think we can avoid but i wanted to see how you do so
[doctor] do you have any questions about that
[patient] yeah i did n't know what those last two things or just
[doctor] yeah so so we are gon na start you on some antibiotics to help help you with this
[patient] you know possible lyme disease and i'm gon na just order some blood tests just to see exactly what's going on and then you know sometimes people need intravenous antibiotics because lyme disease can cause problems on other organs like your heart that type of thing
[doctor] if not treated appropriately and sometimes we need to give antibiotics through the iv which i'd like to avoid i think that we got this early enough that we can just treat you with some oral antibiotics okay for your second problem of your hypertension you know i think you're doing a really good job let's go ahead and continue you on the lisinopril twenty milligrams once a day and i wan na just go ahead and order a lipid panel just to make sure that everything is okay with your cholesterol how does that sound
[patient] that's fine
[doctor] great and then for your third problem of your diabetes i wan na just go ahead and order a hemoglobin a1c and continue you on the metformin one thousand milligrams twice a day it sounds like you're doing a good job since your blood sugars are running in the one twenties i do n't think we need to make any adjustments but we'll see what the hemoglobin a1c shows that gives us a an idea of what your blood sugars are doing on a long-term basis how does that sound
[patient] okay at what point time do you start kinda checking kidney function i've been told that metformin can possibly cause some kidney issues
[doctor] so it can you know your kidney function we've you know i think you've been really lucky it's been normal i checked it about two months ago and it looks pretty good it looks pretty normal but since we're doing blood work on you i can go ahead and order a a basic metabolic panel just to make sure that your kidney function is stable
[patient] okay that'd be good
[doctor] okay anything else
[patient] not that i can think of at this time as soon as i leave
[doctor] well you know where to find me okay
[patient] alright
[doctor] take care bye | CHIEF COMPLAINT
Tick bite.
MEDICAL HISTORY
Patient reports a history of arthritis, hypertension, and diabetes type 2.
SOCIAL HISTORY
Patient reports he enjoys spending time outside in the woods and working in the yard. He went hunting with his grandchildren a couple of weeks ago.
MEDICATIONS
Patient reports taking lisinopril 20 mg once a day and metformin 1000 mg twice daily most of the time.
REVIEW OF SYSTEMS
Constitutional: Reports general ill feelings. Denies any fever, chills, flu like symptoms, body aches, or trouble waking.
Respiratory: Denies cough or shortness of breath.
Musculoskeletal: Denies joint pain or problems with ambulation.
Skin: Reports warmth on the right knee.
Neurological: Reports headache. Denies dizziness.
VITALS
Blood Pressure: 122/70 mmHg.
Heart Rate: 67 beats per minute.
Body Temperature: 98.4 degrees F.
PHYSICAL EXAM
Neck
- General Examination: Neck is supple without thyromegaly or lymphadenopathy.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.
Musculoskeletal
- Examination of the right knee: Erythema and edema as well as an area of fluctuance noted over the right patella. There is pain to palpation of the right anterior knee. Full range of motion.
Integumentary
- Examination: There is evidence of a bull’s eye rash over the right knee.
RESULTS
Patient's previous kidney function is within normal limits.
ASSESSMENT AND PLAN
1. Tick bite.
- Medical Reasoning: My concern is that he might have Lyme disease based on the presentation of his right knee.
- Patient Education and Counseling: The patient and I discussed blood testing to determine if he does in fact have Lyme disease. I explained that Lyme disease can cause problems with other organs if not treated appropriately. We discussed that sometimes antibiotics need to be administered intravenously if oral antibiotics are not given early enough. We will see how he does with a course of oral antibiotics as I would like to avoid intravenous antibiotics.
- Medical Treatment: Prescription for doxycycline 100 mg twice a day for 3 weeks provided. Lyme titer and Western blot will be obtained to determine if he has Lyme disease.
2. Hypertension.
- Medical Reasoning: This is well-controlled at this time.
- Patient Education and Counseling: The patient and I discussed that he is doing really well monitoring his blood pressure at home.
- Medical Treatment: Continue lisinopril 20 mg once a day. Lipid panel ordered to assess his cholesterol levels.
3. Diabetes type 2.
- Medical Reasoning: He is doing a good job managing his diabetes since his blood sugars are running in the 120s. I do not think we need to make any adjustments, but we will see what the hemoglobin A1c shows as that gives us an idea of what his blood sugars are doing on a long-term basis.
- Patient Education and Counseling: We discussed that metformin can affect kidney function; however, his kidney function was last checked 2 months ago, and it has remained within normal limits.
- Medical Treatment: Continue metformin 1000 mg twice a day. Hemoglobin A1c ordered. Basic metabolic panel ordered to assess kidney function.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N088 | virtassist | [doctor] hi , andrew . how are you ?
[patient] hey , good to see you .
[doctor] i'm doing well , i'm doing well .
[patient] good .
[doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ?
[patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse .
[doctor] okay . all right . um , now , have you had your covid vaccines ?
[patient] yeah , both .
[doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ?
[patient] none whatsoever .
[doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ?
[patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me .
[doctor] okay . and are you coughing up anything ?
[patient] not yet , but i feel like that's next .
[doctor] okay . and fevers ?
[patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself .
[doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ?
[patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags .
[doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ?
[patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working .
[doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ?
[patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part .
[doctor] okay and have they been elevated at all since this episode of your-
[patient] no .
[doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ?
[patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control .
[doctor] but you're taking your medication ?
[patient] yes .
[doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ?
[patient] no .
[doctor] anything like that ?
[patient] no .
[doctor] okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , Sarah , show me the vital signs . so , your vital signs here in the office look quite good .
[patient] mm-hmm .
[doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ?
[patient] sure .
[doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ?
[patient] mm-hmm .
[doctor] hey , Sarah . show me the chest x-ray .
[doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ?
[patient] good .
[doctor] hey , Sarah . show me the diabetic labs .
[doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight .
[patient] mm-hmm .
[doctor] i'd like to see that a little bit better , around six or seven , if possible .
[patient] mm-hmm .
[doctor] um , so let's talk a little bit about my assessment and my plan for you .
[patient] mm-hmm .
[doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid .
[patient] mm-hmm .
[doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing .
[patient] mm-hmm .
[doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ?
[patient] you got it .
[doctor] for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ...
[patient] mm-hmm .
[doctor] . refer you to psychotherapy , if you think that that would be helpful .
[patient] mm-hmm .
[doctor] would you like that ?
[patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that .
[doctor] okay . all right .
[doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily .
[patient] mm-hmm .
[doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ?
[patient] okay , sure .
[doctor] hey , Sarah . order a hemoglobin a1c .
[doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day .
[patient] mm-hmm .
[doctor] and i'm gon na go ahead and order a lipid panel , okay ?
[patient] sure .
[doctor] do you need a refill of the lisinopril ?
[patient] actually , i do .
[doctor] okay . hey , Sarah . order lisinopril , 20 milligrams daily .
[doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months .
[patient] okay .
[doctor] let me know if your symptoms worsen and we can talk more about it , okay ?
[patient] you got it .
[doctor] all right . hey , Sarah . finalize the note . | CHIEF COMPLAINT
Upper respiratory infection.
HISTORY OF PRESENT ILLNESS
Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.
The patient reports that he has been doing a bit of work out in the yard in the last week or so. He started to feel really tired and short of breath. The patient denies coughing up anything, but he feels like he will soon be coughing up phlegm. He denies having a fever, but he felt a little warm. He attributed this to exerting himself. He reports that his elbows hurt quite a bit. He notes his knees were pretty tired and he felt some tension around his knees. The patient attributes these symptoms to lifting heavy bags. He has not been wearing a mask as much recently. He believes that he caught his first cold and his symptoms have worsened. He has had both of his COVID vaccinations.
He denies any history of seasonal allergies.
Regarding his depression, he states it has been a crazy year and a half. He was a little concerned about that, but for the most part, he has been doing well with it. His wife got him into barre classes and this has been relaxing.
Regarding his diabetes, he has been monitoring his sugar levels while he is at work, but is not as consistent on Saturdays and Sundays. His diet has been pretty good for the most part, except for some house parties. They have not been elevated since his respiratory symptoms began.
The patient has been monitoring his blood pressure at home. He reports that he is very regular with monitoring his blood pressure during the week, though less consistently on weekends. He reports his blood pressure has been under control. He has continued to utilize lisinopril 20 mg, daily.
The patient denies nausea, vomiting, diarrhea.
REVIEW OF SYSTEMS
• Constitutional: Denies fever.
• Cardiovascular: Endorses dyspnea on exertion.
• Respiratory: Endorses shortness of breath and cough.
• Gastrointestinal: Denies nausea or diarrhea.
• Musculoskeletal: Endorses bilateral elbow and knee pain.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Respiratory: Scattered rhonchi bilaterally, clears with cough.
• Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds.
• Musculoskeletal: Edema in the bilateral lower extremities. Pain to palpation of the bilateral elbows.
RESULTS
X-ray of the chest is unremarkable. No airspace disease. No signs of pneumonia.
Hemoglobin A1c is elevated at 8.
ASSESSMENT AND PLAN
Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.
Upper respiratory infection.
• Medical Reasoning: I believe he has contracted a viral syndrome. His chest x-ray was unremarkable and he has received both doses of the COVID-19 vaccination.
• Additional Testing: We will obtain a COVID-19 test to rule this out.
• Medical Treatment: I recommend he use Robitussin for cough, as well as ibuprofen or Tylenol if he develops a fever.
Depression.
• Medical Reasoning: He has been practicing barre classes and is doing well overall.
• Medical Treatment: I offered medication or psychotherapy, but the patient opted to defer at this time.
Diabetes type 2.
• Medical Reasoning: His blood glucose levels have been well controlled based on home monitoring, but his recent hemoglobin A1c was elevated.
• Additional Testing: We will repeat a hemoglobin A1c in 4 months.
• Medical Treatment: We will increase his metformin to 1000 mg twice daily.
Hypertension.
• Medical Reasoning: He has been compliant with lisinopril and his blood pressures have been well controlled based on home monitoring.
• Additional Testing: We will order a lipid panel.
• Medical Treatment: He will continue on lisinopril 20 mg once daily. This was refilled today.
Follow up: I would like to see him back in approximately 4 months.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N089 | virtassist | [doctor] hi andrea , how are you ?
[patient] i'm doing well . how are you ?
[doctor] doing well . uh , so i know the nurse told you about dax . i'd like to tell dax a little bit about you . okay ?
[patient] okay .
[doctor] so , andrea is a 52-year-old female with a past medical history significant for rheumatoid arthritis , atrial fibrillation , and reflux who presents today for her annual exam . so andrea , it's been a year since i saw you . how are you doing ?
[patient] i'm doing well . so , i've been walking like you told me to and , um , exercising and doing yoga , and that's actually helped with my arthritis a lot , just the- the constant movement . so , i have n't had any joint pain recently .
[doctor] okay . good . so , no- no issues with any stiffness or pain or flare ups over the last year ?
[patient] no .
[doctor] okay . and i know that we have you on the methotrexate , are you still taking that once a week ?
[patient] yes , i am .
[doctor] okay . and any issues with that ?
[patient] no .
[doctor] no . okay . and then in terms of your a-fib , how are you doing with that ? are you having any palpitations ? or , i know that you've kind of been in and out of it over the past , you know , year or so .
[patient] yeah . i've still been having palpitations . the- the last one i had was about a week ago . i've noticed that when i start to get stressed , um , they start to flare up again . so , i've been trying meditation , trying running with my dog to try and relieve the stress but it has n't really been working .
[doctor] yeah . i- i know that you had called , um , last month and we- we did that event monitor for you , uh , which we'll take a look at in a few minutes . okay ?
[patient] okay .
[doctor] um , how about um , your reflux ? you know , we had placed you on the protonix , uh , has that helped ? and i know that you were gon na do some dietary modifications .
[patient] yeah . i cut out soda and that- that's helped- seemed to help , and the medication's been helping too . i have n't had a flare up in over , i think , five months .
[doctor] okay . all right . um , so , you know , i know that you did the review of systems sheet when you checked in and , you know , you had- you know , you endorsed the palpitations and you had some nasal congestion . any other symptoms ? you know , chest pain , shortness of breath , nausea or vomiting ?
[patient] no , nothing like that . just the nasal- nasal congestion because of my allergies .
[doctor] okay . all right . okay . well , i'd like to go ahead and do a quick physical exam , okay ?
[patient] okay .
[doctor] all right . hey Sarah , show me the vital signs . okay . so , you're in- here in the office today , it looks like , you know , your heart rate's really good today . it's- it's nice and controlled so that's good . um , i'm just gon na take a look into your heart and lungs and- and i'll let you know what i find . okay ?
[patient] okay .
[doctor] okay . so , on physical examination , um , you know , everything looks really good . on your heart examination , i do appreciate a slight 2/6 systolic- systolic ejection murmur , um , which we've heard in the past so i'm not worried at that . you're in the- a nice regular rate and rhythm at this time . your lungs are nice and clear . on your right elbow , i do notice some edema and some erythema . does it hurt when i press it ?
[patient] yeah , it does a bit .
[doctor] okay . so , she has pain to palpation of the right elbow . um , and you have no lower extremity edema , okay ? um , so i wan na go ahead and just take a look at some of your results . okay ?
[patient] okay .
[doctor] hey Sarah , show me the event- event monitor results . okay . so , you know , this is the results of your event monitor which shows that , you know , you're in and out of a-fib , you have what we call a conversion pause . you know , you're in a-fib , you pause , and then you go back to regular rhythm . so , we'll talk about that , okay ?
[patient] okay .
[doctor] hey Sarah , show me the autoimmune panel . so , looking here at your autoimmune panel , everything looks good , it looks like you're- you know , everything is well controlled with your rheumatoid arthritis on the methotrexate . okay ? so , let me just go over a little bit about my assessment and my plan for you . okay ?
[patient] okay .
[doctor] so for your first problem , your rheumatoid arthritis , again , everything looks good . i wan na just continue you on the methotrexate 2.5 mg , once weekly . um , and uh , if you need a referral back to see the rheumatologist , let me know , but i think everything seems stable now . do you need a refill of the methotrexate ?
[patient] yes , i do .
[doctor] okay . hey Sarah , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ?
[patient] okay .
[doctor] hey Sarah , order a referral to cardiology . and for your last problem , the reflux , you know , i wanna- i want you to just continue on the protonix , 40 mg a day . continue with your dietary modifications , you know , avoiding coffee and spicy foods , that type of thing . okay ? and then let me know if you have any other issues with that , okay ?
[patient] will do .
[doctor] any questions ?
[patient] no , i do n't .
[doctor] okay . all right . it was good to see you .
[patient] good seeing you .
[doctor] hey Sarah , finalize the note . | CHIEF COMPLAINT
Annual exam.
HISTORY OF PRESENT ILLNESS
Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.
The patient states she is doing well. She has been walking, exercising, and doing yoga, which has helped with her arthritis. She denies issues with stiffness, pain, or flare ups over the last year. The patient has continued utilizing methotrexate 2.5 mg once a week and denies issues with that.
In terms of her atrial fibrillation, she endorses continued palpitations. The last episode she had was about 1 week ago. She has noticed that when she starts to get stressed they start to flare up again. She has tried meditation and running with her dog for stress relief, however these have not been helpful. The patient had called last month and had an event monitor done.
Regarding her GERD, she has continued to utilize Protonix 40 mg a day. The patient has cut out soda, which seemed to help. She has not had a flare up in over 5 months.
The patient endorses nasal congestion because of her allergies. She denies chest pain, shortness of breath, nausea, and vomitting.
REVIEW OF SYSTEMS
• Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies.
• Cardiovascular: Denies chest pain or dyspnea. Endorses palpitations.
• Respiratory: Denies shortness of breath.
• Musculoskeletal: Denies joint pain.
PHYSICAL EXAMINATION
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. Slight 2/6 systolic ejection murmur.
• Musculoskeletal: No lower extremity edema. Edema and erythema of the right elbow. Pain to palpation of the right elbow.
RESULTS
Event monitor: Positive for conversion pause.
Autoimmune panel: Normal. Well controlled rheumatoid arthritis.
ASSESSMENT AND PLAN
Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.
Rheumatoid arthritis.
• Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal.
• Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today.
• Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know.
Atrial fibrillation.
• Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause.
• Specialist Referrals: We will refer her to cardiology for a cardiac ablation.
GERD.
• Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months.
• Medical Treatment: Continue on Protonix 40 mg daily.
• Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N090 | virtassist | [doctor] hi , albert . how are you ?
[patient] hey , good to see you .
[doctor] it's good to see you too . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] so , albert is a 62-year-old male , with a past medical history significant for depression , type 2 diabetes , and kidney transplant , who is here today for emergency room follow-up .
[patient] mm-hmm .
[doctor] so , i got a notification that you were in the emergency room , but , but what were you there for ?
[patient] well , i , uh , i was n't really , uh , staying on top of my , uh , blood sugar readings , and i felt kinda woozy over the weekend . and i was little concerned , and my wife wanted to take me in and just have me checked out .
[doctor] okay . and , and was it , in fact , high ?
[patient] yeah , it was .
[doctor] okay . did you ... were you admitted to the hospital ?
[patient] uh , no .
[doctor] okay . all right . and , uh , are you ... did they see a reason , as to why it was elevated ?
[patient] uh , yeah . my mother was actually in the hospital the last week. she had a bit of a fall and had to do a hip replacement. she's feeling better now but we have been just grabbing meals at the cafeteria or picking up fast food on our way home and i just really was n't monitoring what i was eating .
[doctor] okay . that's sorry to hear . and are you feeling better now ?
[patient] uh , actually , when we got home from the , uh , f- from the visit , i felt a lot better .
[doctor] okay . and since then , have you been following your diet pretty closely ?
[patient] yes .
[doctor] okay . 'cause we do n't wan na end up in the hospitaltoo
[patient] no .
[doctor] all right . um , okay . and , so , before that happened , how are you doing with your diet ?
[patient] uh , during the week , i've been fine , 'cause i've been very busy . on the weekends , doing things . you're seeing people . you're having people over . it's , i- not , not as consistent on the weekend .
[doctor] okay . all right . um , is there a way that you think that that can improve ?
[patient] uh , s- stop eating .
[doctor] okay . all right . well , let's talk about your , your kidney transplant . how are-
[patient] mm-hmm .
[doctor] . you doing ? you're taking immunotherapy meds ?
[patient] yes .
[doctor] okay .
[patient] yeah . i've , i've been pretty diligent about it , following doctor's orders , so it's been , it's been pretty good so far .
[doctor] okay . and , and y- the last time i saw that you saw dr. reyes , was about three weeks ago , and everything seemed to be fine .
[patient] that's correct .
[doctor] your kidney function is good .
[patient] yes .
[doctor] okay . all right . and in terms of your depression , how are you , how are you doing ?
[patient] and it's been about a , a tough , ugh , year-and-a-half or so , but i've been pretty good with it . i , i have my moments , but i- as long as i find some time to relax , at least in the afternoon , then , then it seems to work out okay .
[doctor] okay . so , i know that we've kind of talked about holding off on medical therapy-
[patient] mm-hmm .
[doctor] . 'cause you're on so many other meds .
[patient] mm-hmm .
[doctor] um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ?
[patient] uh , i think i probably wan na shy away from any therapy . my , my wife got me into meditation recently and , and , uh , i , i find that relaxing . so , i think i'd like to continue that , at least for a couple more months and see how it goes .
[doctor] okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you-
[patient] mm-hmm .
[doctor] . checked in . do you have any symptoms , any chest pain or shortness of breath ?
[patient] none whatsoever .
[doctor] lightheadedness ? dizziness ?
[patient] no .
[doctor] no ? okay . um , and i just wan na go ahead and do a quick physical exam .
[patient] mm-hmm .
[doctor] hey , Sarah . show me the vital signs .
[doctor] so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be .
[patient] mm-hmm .
[doctor] so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ?
[patient] sure .
[doctor] okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past .
[patient] mm-hmm .
[doctor] your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ?
[patient] mm-hmm .
[doctor] um , so , let's go ahead . i wan na look at some of your results . okay ?
[patient] sure .
[doctor] hey , Sarah . show me the glucose .
[doctor] so , right now , your blood sugar is about 162 . have you eaten before you came in here ?
[patient] i did not .
[doctor] okay . all right . um , hey , Sarah . show me the diabetes labs .
[doctor] okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high .
[patient] mm-hmm .
[doctor] so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated .
[patient] mm-hmm .
[doctor] so , we'll talk about , you know , how to go ahead and , and fix that . okay ?
[doctor] so , let me talk a little bit about my assessment and my plan for you .
[patient] mm-hmm .
[doctor] so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further .
[patient] mm-hmm .
[doctor] okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , Sarah . order a hemoglobin a1c .
[doctor] for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ?
[patient] mm-hmm .
[doctor] okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications .
[patient] okay .
[doctor] um , and then , he knows to reach out to me if he needs anything . okay ?
[patient] you got it .
[doctor] all right . well , the nurse will be in soon to check you out . okay ?
[patient] perfect .
[doctor] hey , Sarah . finalize the note . | CHIEF COMPLAINT
ER follow-up.
HISTORY OF PRESENT ILLNESS
Albert Powell is a 62-year-old male with a past medical history significant for depression, type 2 diabetes, and kidney transplant. He is here today for an emergency room follow-up.
The patient states he was not staying on top of his blood sugar readings and felt " woozy " over the weekend. His wife was concerned that his levels were elevated and wanted to take him to the emergency room. He was not admitted to the hospital. He reports that his mother is in the hospital and he has been eating poorly. He was not monitoring his blood sugars and what he was eating. When they got home from the visit he felt a lot better. Since then, he has been following his diet pretty closely. He continues Lantus insulin at bedtime.
Regarding his kidney transplant and has been doing pretty well. The patient has been pretty diligent about taking immunotherapy medication and following orders. The last time he saw Dr. Reyes was about 3 weeks ago and everything seemed to be fine.
Regarding his depression, the patient states it has been about a year and a half, but he has been pretty good with that. He has his moments, but as long as he finds some time to relax in the afternoon and then it seems to work out. He thinks he would probably want to continue that at least for a couple more months and see how it goes. His wife got him into meditation recently and he finds that relaxing so he feels he would like to continue that for a couple more months and see how it goes.
The patient denies any chest pain, shortness of breath, lightheadedness or dizziness.
REVIEW OF SYSTEMS
• Cardiovascular: Denies chest pain or dyspnea.
• Respiratory: Denies shortness of breath.
• Neurological: Denies lightheadedness or dizziness.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Constitutional: in no apparent distress.
• Neck: No carotid bruits appreciable.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Grade 2/6 systolic ejection murmur.
• Musculoskeletal: 1+ edema in the bilateral lower extremities.
RESULTS
Fasting glucose is elevated at 162.
Hemoglobin A1c is elevated at 8.
ASSESSMENT AND PLAN
Albert Powell is a 62-year-old male with a past medical history significant for depression, type 2 diabetes, and kidney transplant. He is here today for an emergency room follow-up.
Hyperglycemia.
• Medical Reasoning: He was recently seen in the emergency department with elevated blood glucose levels. He admits to dietary indiscretion prior to this, but has since improved his diet. His recent blood glucose level was 162, and his recent hemoglobin A1c was 8.
• Additional Testing: Repeat hemoglobin A1c in a few months.
• Medical Treatment: Increase Lantus to 20 units at night.
• Patient Education and Counseling: I advised him to continue monitoring his blood glucose levels at home and report those to me, as we may need to make further adjustments to his medication.
Depression.
• Medical Reasoning: He reports personal stressors over the past year and a half but is doing well overall. He recently started meditating.
• Medical Treatment: He should continue his current management strategies. We will hold off on medication and therapy at this time.
• Patient Education and Counseling: The patient was encouraged to contact me if he needs anything.
Status post renal transplant.
• Medical Reasoning: His kidney function appears stable and he has been compliant with his immunotherapy medications.
• Medical Treatment: Continue seeing Dr. Reyes for management of his immunosuppression medication.
• Patient Education and Counseling: He knows to reach out to me if he needs anything.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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D2N091 | virtassist | [doctor] hi jerry , how are you doing ?
[patient] hi , good to see you .
[doctor] good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you .
[patient] sure .
[doctor] jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sclerosis who presents for an annual exam . so jerry , what's been going on since the last time i saw you ?
[patient] uh , we have been traveling all over the country . it's been kind of a stressful summer . kinda adjusting to everything in the fall and so far it's been good , but ah , lack of sleep , it's been really getting to me .
[doctor] okay . all right . and have you taken anything for the insomnia . have you tried any strategies for it .
[patient] i've tried everything from melatonin to meditation to , uh , t- stretching out every morning when i get up . nothing really seems to help though .
[doctor] okay . all right .
[doctor] in terms of your osteoporosis , i know we have you on fosamax , any issues with your joints , any issues like-
[patient] no .
[doctor] no broken bones recently ?
[patient] no .
[doctor] no , nothing like that ?
[patient] no .
[doctor] okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ?
[patient] uh , about six months ago .
[doctor] okay and you're taking the medication ?
[patient] yes .
[doctor] okay . and any issues with that ?
[patient] none whatsoever .
[doctor] and any additional weakness ? i know you were having some issues with your right leg , but that seems to have improved or ?
[patient] yes a lingering issue with my knee surgery . but other than that it's been fine .
[doctor] okay .
[patient] pretty , pretty strong , n- nothing , nothing out of the ordinary .
[doctor] okay . all right , well i know you did a review of systems sheet when you checked in .
[patient] mm-hmm .
[doctor] and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ?
[patient] no .
[doctor] all right . well lets go ahead and do a quick physical exam .
[patient] mm-hmm .
[doctor] hey Sarah , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find .
[patient] sure .
[doctor] okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee .
[patient] mm-hmm .
[doctor] um , so let's go over some of your results , okay ?
[patient] sure .
[doctor] hey Sarah , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . do you need a refill on that ?
[patient] actually i do .
[doctor] hey Sarah , order a refill of fosamax 1 tab per week , 11 refills . and then in t- , for your second problem , your multiple sclerosis i want you to go ahead and continue to see the neurologist and continue on those medications . and let me know if you need anything from that standpoint , okay ?
[patient] you got it .
[doctor] any questions ?
[patient] not at this point , no .
[doctor] okay , great . hey Sarah , finalize the note . | CHIEF COMPLAINT
Annual exam.
HISTORY OF PRESENT ILLNESS
Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam.
The patient states he has been traveling all over the country. He notes it has been a stressful summer and adjusting to everything in the fall.
The patient reports a lack of sleep. He has tried melatonin, meditation, and stretching every morning, but nothing has helped.
For treatment of his osteoporosis, he is on Fosamax. He denies any issues with his joints. He denies any recent broken bones.
Regarding his multiple sclerosis, he last saw the neurologist 6 months ago. He is taking his medication and denies any issues with this. Previously, he experienced right leg weakness, however, this has resolved.
He does have some lingering issues with his right knee after previous surgery, but nothing out of the ordinary.
The patient denies any chest pain or shortness of breath.
REVIEW OF SYSTEMS
• Cardiovascular: Denies chest pain or dyspnea.
• Respiratory: Denies shortness of breath.
• Musculoskeletal: Endorses right knee discomfort.
• Neurological: Endorses insomnia.
PHYSICAL EXAMINATION
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Musculoskeletal: Weakness in the lower extremities, 4/5 on the right and 3/5 on the left. Reflexes are good. Arthritic changes in the right knee.
RESULTS
X-ray of the right knee demonstrates some arthritic changes.
ASSESSMENT
Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam.
PLAN
Osteoporosis.
• Medical Reasoning: The patient is doing well with Fosamax.
• Medical Treatment: Continue Fosamax 1 tab per week. Eleven refills were ordered today.
Multiple Sclerosis.
• Medical Reasoning: The patient is experiencing weakness of the bilateral lower extremities. He has been seeing his neurologist on a consistent basis and has been compliant with medication.
• Medical Treatment: He will continue to follow up with his neurologist and comply with his medication regimen.
Right knee arthritis.
• Medical Reasoning: The patient recently underwent knee surgery. A recent right knee x-ray demonstrated some arthritic changes.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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D2N092 | virtassist | [doctor] hello , mrs . martinez . good to see you today .
[patient] hey , dr . gomez .
[doctor] hey , Sarah , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ?
[patient] um , my arm hurts right here . kind of toward my wrist . this part of my arm .
[doctor] so you have pain in your distal radius ?
[patient] yes .
[doctor] how did that happen ?
[patient] um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm .
[doctor] okay . and did it swell up at all ? or-
[patient] it did . it got a ... it had a little bit of swelling . not a lot .
[doctor] okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ?
[patient] a little bit when i move my wrist . um , no numbness in my hand .
[doctor] okay . do you have any past medical history of anything ?
[patient] um , yes . allergic , um , l- i have allergies . and so i take flonase .
[doctor] okay . and any surgeries in the past ?
[patient] yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work-
[doctor] okay .
[patient] on my rake .
[doctor] okay .
[patient] yeah .
[doctor] i was wondering where you were going to go with that .
[patient] yeah .
[doctor] okay . great . so , let's take a look at , uh , the x-ray of your arm . hey Sarah , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you .
[patient] okay .
[doctor] does it hurt when i press on your arm here ?
[patient] yes .
[doctor] okay . how about when i bend your arm ?
[patient] yes .
[doctor] okay . that's pretty tender , ?
[patient] mm-hmm .
[doctor] how about when i go backwards like that ?
[patient] not as much .
[doctor] and how about when i flex like this ?
[patient] a little .
[doctor] but mostly when i do that type of motion ?
[patient] yes .
[doctor] okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again .
[patient] okay .
[doctor] okay , great . hey Sarah , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . Sarah you can finalize the note .
[patient] thank you . | CC:
Right arm pain.
HPI:
Ms. Martinez is a 43-year-old female who presents today for an evaluation of right arm pain after she hitting her arm on a pole while playing tennis. She had mild swelling at the time. There is pain with motion. She denies any numbness or tingling in her hand. She has a past medical history of allergies and takes Flonase.
EXAM
Examination of the left wrist shows tenderness over the distal radius and pain with flexion of the wrist and thumb.
RESULTS
X-rays of the left wrist show no obvious signs of acute fracture or other abnormality.
IMPRESSION
Right wrist sprain.
PLAN
At this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and anti-inflammatory medications. I am prescribing Motrin, 800 mg to take 3 times a day with food. She will follow up with me in 1 week or as needed.
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D2N093 | virtassist | [doctor] hey lawrence . how are you ?
[patient] hey , good to see you .
[doctor] it's good to see you too . so , i know the nurse told you about dax .
[patient] mm-hmm .
[doctor] i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ?
[patient] uh , i , i've noticed that i've been swelling up a little bit . i think a lot of it has to do with going to some house parties , eating some salty foods . i feel really lethargic .
[doctor] okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ?
[patient] it's something like walking up a flight of stairs i'll actually feel it .
[doctor] okay . all right . now , um , how long has this been going on for ?
[patient] probably about 10 days .
[doctor] okay . all right . and you said you're noticed some swelling in your legs ?
[patient] a little bit .
[doctor] okay . do you have problems lying flat in bed ?
[patient] um , i'm a little uncomfortable when i wake up in the morning and i feel pretty stiff . and , and , like , it takes me a little while to adjust to walking when i get up .
[doctor] okay . all right . do you ever wake up acutely short of breath at night ?
[patient] um , it happened once , probably about a week ago , but it has n't happened since . so i have n't been that concerned about it .
[doctor] okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump .
[patient] mm-hmm .
[doctor] um , are your blood sugars okay ? have you noticed a spike in them recently ?
[patient] um , i have n't . i've been pretty good about monitoring it so i ... during the working week , i stay on top of that . but on saturdays or sundays we're so busy i forget to monitor it . but i have n't seen anything spike .
[doctor] okay . and i remember your affinity for chocolate bars , so ...
[patient] guilty as charged . i love chocolate bars .
[doctor] okay . all right . so , in terms of your depression , how are you doing with that ?
[patient] uh , it's been a crazy year and a half . um , i've tried some natural solutions . in the summer i did stretches outdoors every morning , which was great , but now the weather changed and , uh , you know , i've got ta find some alternatives . i'm not ready to try any medications just yet , so-
[doctor] okay .
[patient] . i'm open to some suggestions .
[doctor] okay . we'll talk about that .
[patient] sure .
[doctor] and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole .
[patient] mm-hmm .
[doctor] you were making some lifestyle modifications , cutting back on your red bull and caffeine .
[patient] yeah .
[doctor] alcohol intake has been ... how's that been ?
[patient] tough during the holiday season , but i'm , i'm better .
[doctor] okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ?
[patient] no . no . absolutely not .
[doctor] okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath .
[patient] mm-hmm .
[doctor] any other symptoms ? chest pain , fever , chills , cough ?
[patient] no .
[doctor] um , belly pain ?
[patient] no .
[doctor] okay . let's go ahead . i want to move on to a physical exam .
[patient] mm-hmm .
[doctor] hey , Sarah ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find .
[patient] mm-hmm .
[doctor] okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion .
[patient] mm-hmm .
[doctor] but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , Sarah ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ?
[patient] okay .
[doctor] hey , Sarah ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good .
[patient] mm-hmm .
[doctor] so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every day .
[patient] mm-hmm .
[doctor] if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911-
[patient] mm-hmm .
[doctor] . and go into the emergency room . you might need some intravenous diuretics .
[patient] mm-hmm .
[doctor] okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ?
[patient] sure .
[doctor] no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ?
[patient] not at this point .
[doctor] okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ?
[patient] you got it .
[doctor] hey , Sarah ? finalize the notes ... | CHIEF COMPLAINT
Shortness of breath.
HISTORY OF PRESENT ILLNESS
Lawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath.
The patient states he has had some shortness of breath and mild leg swelling which he thinks has to do with eating some salty foods at some house parties recently. His shortness of breath is primarily with exertion such as walking up the stairs. This has been going on for about 10 days now. He woke from sleep once with shortness of breath about a week ago. He also notes discomfort lying flat in bed and musculoskeletal stiffness in the morning. He states that it takes him a little while to get up.
Regarding his type 1 diabetes, he is using his insulin pump. He has been consistently monitoring his blood sugars during the working week, but notes that he checks less on the weekends, due to being busy. He is trying to avoid sugar but admits to an affinity for chocolate bars.
Regarding his depression, he states that it has been a crazy year and a half. He has tried some natural solutions. In the summer, he did daily outdoor stretching, which was great; but now that the weather has changed, he needs to find some alternatives. He is not ready to try any medications. He denies suicidal and homicidal ideation.
Regarding his GERD, he is taking his omeprazole. He has made some lifestyle modifications like cutting back on his red bull intake and other caffeine. Reducing his alcohol intake has been tough during the holiday season, but he is getting better about this.
The patient denies chest pain, fever, chills, cough, and abdominal pain.
REVIEW OF SYSTEMS
• Constitutional: Denies fevers, chills. Endorses fatigue.
• Cardiovascular: Denies chest pain. Endorses dyspnea on exertion.
• Respiratory: Denies coughor wheezing. Endorses shortness of breath..
• Musculoskeletal: Endorses lower extremity edema.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Neck: No carotid bruits appreciable. No jugular venous distention.
• Respiratory: Rales are heard bilaterally at lung bases.
• Cardiovascular: 3/6 systolic ejection murmur.
• Musculoskeletal: 1+ pitting bilateral lower extremity edema.
RESULTS
Chest x-ray did not show any evidence of airspace disease.
Labs were all within normal limits, including the WBC.
ASSESSMENT
Lawrence Walker is a 62-year-old male with a past medical history significant for type 1 diabetes, congestive heart failure, depression, and reflux, who presents with complaints of shortness of breath.
PLAN
Acute heart failure exacerbation.
• Medical Reasoning: The patient is retaining fluid. He has noticed increased fluid retention following dietary indiscretion. He has experienced dyspnea on exertion for the past 10 days.
• Medical Treatment: Initiate Lasix 40 mg a day.
• Patient Education and Counseling: I advised the patient to monitor and log his daily weights. He will contact me if these continue to increase. He was instructed to call me or 911 if he experiences dyspnea at rest.
Type 1 diabetes.
• Medical Treatment: This is currently stable with use of an insulin pump.
• Additional Testing: I will order a hemoglobin A1c in 1 month.
• Medical Treatment: He will continue the insulin pump. The patient will follow up with his endocrinologist.
• Patient Education and Counseling: I encouraged the patient to have an eye exam.
Depression.
• Medical Reasoning: The patient has been doing well with outdoor stretching. He continues to decline the use of medications for this issue.
• Medical Treatment: I will refer him to psychiatry as his current management strategy is unsustainable due to the change in season.
• Patient Education and Counseling: We will defer initiating medication at this time.
Acid reflux.
• Medical Reasoning: His symptoms are stable with medication.
• Medical Treatment: Continue omeprazole 20 mg a day.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. his endo |
D2N094 | virtassist | [doctor] hey , ms. james . nice to meet you .
[patient] nice to meet you , dr. cooper . how are you ?
[doctor] i'm well . hey , Sarah , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ?
[patient] i hurt my , uh , finger when i was skiing this past weekend .
[doctor] really ?
[patient] yeah . yeah , so , um , i was going down hill , double diamonds , uh , double black diamonds , and i just lost control , and i , you know , flipped down a few ways , but , uh , somewhere along the way , i , i jammed my , my index finger on something . i'm not sure what .
[doctor] okay . so this happened last saturday , you said ?
[patient] it was saturday , yes .
[doctor] okay . so about five days of this right index finger pain .
[patient] mm-hmm .
[doctor] have you taken any medicine for it ?
[patient] i took some ibuprofen . um , did n't really seem to help .
[doctor] okay . have you iced it or put a splint on it ?
[patient] no .
[doctor] okay . and what would you rate your pain ?
[patient] it's about a seven .
[doctor] a seven out of 10 pain . um , and no other injuries while you went down this double black diamond ?
[patient] no , interestingly enough , this is the only one .
[doctor] okay . well , i guess you escaped ... i mean ...
[patient] could have been much worse .
[doctor] could have been much worse , yes . so , um , do you have any medical problems ?
[patient] um ... yeah , i'm ... i have chronic constipation .
[doctor] do you take any medicine for it ?
[patient] miralax .
[doctor] and does that help ?
[patient] seems to flow nicely .
[doctor] good for you .
[doctor] um ... have you ever had any surgeries before ?
[patient] yes , i had my appendix out when i was seven .
[doctor] okay . um , let's look at your x-ray together . hey , Sarah , show me the last x-ray . all right . so looking at your right hand here , and that index finger looks great . so all the joints , bones are in the right places , no fractures , so you've got a normal right hand x-ray . um , let's go ahead and check your finger out . now does it hurt when i push on your finger like this ?
[patient] yes .
[doctor] does it hurt when i pull your finger like this ?
[patient] yes .
[doctor] does it hurt when i squeeze over this joint here ?
[patient] yes . please do n't do that .
[doctor] does it hurt when i squeeze over this ?
[patient] yes .
[doctor] okay . um ... so with your x-ray , and with your exam , looks like you have a sprain of your distar- distal interphalangeal joint . it's called your dip joint , of your right index finger , and so what we're gon na do for that is we're gon na put a splint on that right finger . i'm gon na give you a strong antiinflammatory called mobic . you'll take 15 milligrams once a day . i'll prescribe 14 of those for you . and i want you to come back and see me in two weeks , and let's make sure it's all healed up and if we need to start any hand therapy at that point , then we can . do you have any questions for me ?
[patient] no questions . thank you .
[doctor] you're welcome . hey , Sarah , order the medications and procedures mentioned . and why do n't you come with me , and we'll get you checked out ?
[patient] okay .
[doctor] hey , Sarah , finalize the report . | CC:
Right index finger pain.
HPI:
Ms. James is a 42-year-old female who presents today for an evaluation of right index finger pain. She states she injured it while skiing. She states she fell and jammed her finger. She took Ibuprofen on but it did not help her. She denies any icing it or wearing a splint. She rates her pain 7/10.
CURRENT MEDICATIONS:
MiraLAX
PAST MEDICAL HISTORY:
Chronic constipation
PAST SURGICAL HISTORY:
Appendectomy at age 7.
EXAM
Examination of the right hand reveals pain to palpation of the MCP and DIP joints.
RESULTS
X-rays of the right index finger show no obvious signs of fracture.
IMPRESSION
Right index finger DIP joint sprain.
PLAN
At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. A prescription is provided for Mobic 15 mg once a day, dispense 14. She will follow up with me in 2 weeks for a repeat evaluation. If she is unimproved, we will consider hand therapy at that time. All questions were answered.
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D2N095 | virtassist | [doctor] hi , cheryl . how are you ?
[patient] i'm doing well . how are you ?
[doctor] i'm doing well . so i know the nurse told you a little bit about dax . i'd like to tell dax about you .
[patient] okay .
[doctor] cheryl is a 34-year-old female with a past medical history significant for hypertension , who presents today with back pain . cheryl , what happened to your back ?
[patient] so i've been walking a lot lately . i've been walking to ... 30 minutes to an hour or so a day . and all of a sudden , um , when i was walking , my , um , back just kind of seized up on me . and i do n't really know what it was . maybe i was going a little bit faster . but it just all kind of clenched .
[doctor] okay . so you felt like , maybe like a spasm or something like that ?
[patient] yeah .
[doctor] okay . and how many days ago was that ?
[patient] that was about six days ago now .
[doctor] okay . and what have you taken for the pain ?
[patient] i've been taking ibuprofen . um , and then i've been putting some heat on it . but it's still pretty stiff .
[doctor] okay . all right . um , and did you have any trauma before that happened ? were you doing anything strenuous like crossfit or lifting boxes or anything like that before you went for , for the walk ?
[patient] i have been lifting more , um , probably around three times a week . so i do n't know if it was because i was doing deadlifts that day and then walked .
[doctor] okay .
[patient] um , maybe i was using my back more than my legs .
[doctor] okay . all right . and was it any particular area in your back ? was it the lower back ?
[patient] yeah , it was .
[doctor] okay . on one side versus the other ?
[patient] um , kind of both equally .
[doctor] okay . all right . and any numbing or tingling in your legs or your feet ?
[patient] no , i have n't felt anything like that .
[doctor] okay . any weakness in your lower extremities ?
[patient] no .
[doctor] okay . all right .
and then in terms of your blood pressure , how are you doing ?
[patient] so i got that cuff that you suggested the ... our ... the last visit , and i've been doing readings at home . and that's been looking great , too . i've been watching my diet . again , my boyfriend's been great and dieting with me so i do n't have to do it alone . and everything's been good .
[doctor] okay . excellent . and you're taking the lisinopril ?
[patient] yes .
[doctor] okay . wonderful . okay . so i know you did a review of systems sheet with the nurse , and i know you endorse , you know , this back pain . um , do you have any other symptoms ? fever , chills , congestion , cough , chest pain , shortness of breath ?
[patient] i have a little bit of nasal congestion , but that's just from my seasonal allergies .
[doctor] okay . all right . well , let's go ahead . i want to do a quick physical exam on you .
[patient] okay .
[doctor] okay ? hey , Sarah , show me the vital signs . so good- you know , here in the office , your vital signs look great . your blood pressure's really well controlled , which is good . so that's a good job . so i'm going to take a listen to your heart and lungs . i'm going to examine your back , and i'm going to let you know what i find . okay ?
[patient] okay .
[doctor] okay . all right . so on physical examination , you know , everything looks good . you know , on your heart exam , i do hear that slight two out of six systolic ejection murmur , but you've had that before . that seems stable to me . on your back exam , you do have some pain to palpation on the right lateral aspect of your lumbar spine , and you do have pain with flexion and extension as well , and you have a negative straight leg raise . so what does that mean ? so we're going to go over that . okay ? let's ... let me look at some of your results , though , first . okay ?
[patient] okay .
[doctor] we did an x-ray before you saw me , so let's look at that . hey , Sarah , show me the back x-ray . so looking here at this x-ray of the lumbar spine , everything looks good . there's good boney alignment . there's no obvious fracture , you know , which is not surprising based on your history . okay ?
[patient] hmm .
[doctor] hey , Sarah , show me the labs . and your labs that we did before you came in all look great . there's no elevated white blood cell count . there's no signs of infection . again , those are all really good . okay ? so let me go over with you about my assessment and my plan for you . so for your first problem , this back pain , i think you have a lumbar strain , and , you know , that might've happened , you know , lifting something or exercising . and so what i want to do is prescribe meloxicam , 15 milligrams once a day . uh , i want you ... you can ice the area , and you can also apply heat sometimes as well . um , you know , i'm going to refer you to physical therapy just to do some strengthening exercises of your back , um , because i do want you to continue to be able to work out and exercise . okay ?
[patient] okay .
[doctor] and for your last problem , your high blood pressure , again , everything looks great here . um , you know , i think you're doing a really good job with that as well . i want you to continue on the lisinopril , 10 milligrams a day . and then , uh , let me know if you notice any increases in your blood pressure readings . okay ?
[patient] okay .
[doctor] do you need a refill of the lisinopril ?
[patient] yes , i do , actually .
[doctor] okay . hey , Sarah ? order lisinopril 10 milligrams po daily . okay . uh , so the nurse will be in soon , and she'll get you checked out . okay ?
[patient] okay .
[doctor] all right . hey , Sarah ? finalize the note . | CHIEF COMPLAINT
Back pain.
HISTORY OF PRESENT ILLNESS
Ms. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.
The patient reports she has been walking a lot lately, 30 minutes to an hour or so a day. While walking 6 days ago, she felt her back seize up on her. She is not sure what caused it but thinks she was walking a little faster than usual. She describes the sensation as a spasm. She has been taking ibuprofen and using heat on it but it is still pretty stiff. She denies any known trauma or injury to her back. She notes she has been weightlifting around 3 times a week. She did do deadlifts that day before her walk and thinks she may have been using her back more than her legs to lift. She locates the pain in her mid lower back. She denies any lower extremity numbness, tingling, and weakness.
Regarding her hypertension, she states she has been doing readings at home and that has been looking great. She has been watching her diet which has helped. She is taking lisinopril.
The patient endorses nasal congestion, which she attributes to her seasonal allergies.
REVIEW OF SYSTEMS
• Ears, Nose, Mouth and Throat: Endorses nasal congestion from seasonal allergies.
• Musculoskeletal: Endorses bilateral low back pain and stiffness.
• Neurological: Denies numbness.
PHYSICAL EXAMINATION
• Cardiovascular: Slight 2/6 systolic ejection murmur, stable.
• Musculoskeletal: Pain to palpation along the right lateral aspect of her lumbar spine. Pain with flexion and extension. Negative straight leg raise.
RESULTS
Back x-ray reveals good bony alignment with no obvious fracture.
Labs: All within normal limits.
ASSESSMENT AND PLAN
Ms. Ramirez is a 34-year-old female with a past medical history significant for hypertension, who presents today with back pain.
Back pain.
• Medical Reasoning: She experienced a spasm-like pain in her back while walking approximately 6 days ago. She has also been lifting weights recently. Her lumbar spine x-ray was unremarkable and her recent labs were normal. I believe she has a lumbar strain.
• Medical Treatment: We will initiate meloxicam 15 mg once daily.
• Specialist Referrals: We will refer her to physical therapy to work on strengthening exercises.
• Patient Education and Counseling: She may apply ice and heat to the area.
Hypertension.
• Medical Reasoning: This is well controlled with lisinopril and dietary modifications based on home monitoring.
• Medical Treatment: She will continue lisinopril 10 mg daily. This was refilled today.
• Patient Education and Counseling: I encouraged her to continue with home monitoring and report any elevated blood pressures to me.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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D2N096 | virtassist | [doctor] um , hi mrs. anderson . right ?
[patient] yeah . yes , doctor .
[doctor] what brings you here today ?
[patient] hi , doctor . um , i'm having this left shoulder pain lately , uh , and it's paining a lot .
[doctor] okay . all right . hey , Sarah . i am seeing mrs. anderson , a 44-years-old female , uh , complaining to check the left shoulder pain . um , so how long how has this lasted ?
[patient] it's been a week , doctor . yeah .
[doctor] a week .
[patient] yeah .
[doctor] um , did you take any medication yourself ?
[patient] no , i did not take any pain medications . actually , i did . i did take a tylenol for two or three days , but then that did n't help at all . so , uh , the reason why it started or when it started to happen is-
[doctor] yeah .
[patient] . i was actually in gymnastics class .
[doctor] yeah , okay .
[patient] and , uh , i do n't know . maybe i must have toppled over into some weird position , so it started to pain since then , uh , because of a certain move .
[doctor] okay , uh-
[patient] i went overboard , i think . yeah .
[doctor] all right , lem me , uh , take a quick look . uh , can you move up a little bit ? yeah .
[patient] uh , yeah . in fact , that's hurts .
[doctor] does that- does it hurt ?
[patient] yeah , it does .
[doctor] what if you move back a little bit ?
[patient] uh , that also hurts , doctor .
[doctor] yeah , okay .
[patient] any kind of movement on my left shoulder actually hurts .
[doctor] okay . all right , um , so let's ... hey , Sarah . show me the last x-ray . all right , from the x-ray , it does n't look like there is any , uh , broken bone or fracture . my guess is you probably , um , hurt your joint , uh-
[patient] uh- .
[doctor] . a little bit .
[patient] mm-hmm .
[doctor] so i would , uh , suggest you continue using the pain reliever , maybe just like 600 milligram of ibuprofen three times a day and use it for a week .
[patient] and for how long ? yes .
[doctor] for a week .
[patient] a week , okay .
[doctor] and then if you ... if it's still painful , you can use , uh , ice or , um , heat pad-
[patient] okay .
[doctor] . 'cause that might help relieve your pain .
[patient] okay .
[doctor] um ...
[patient] but i wanted you to know that i did have past surgery on my , um , left arm-
[doctor] mm-hmm .
[patient] . so , um , i hope that should n't matter , right ?
[doctor] um , that does n't seem related to your pain .
[patient] okay .
[doctor] so ... but i would try to rest my , your left arm-
[patient] okay .
[doctor] . while it's healing .
[patient] okay .
[doctor] so , um-
[patient] can i , uh , carry any heavy weights or-
[doctor] no , no . definitely not .
[patient] . anything like that ?
[doctor] definitely not .
[patient] okay . okay .
[doctor] yeah , use , um , right hand-
[patient] okay .
[doctor] . instead-
[patient] mm-hmm .
[doctor] . for the next , uh , at least just three to four weeks .
[patient] mm-hmm .
[doctor] uh , come back to see me if the pain , you know , still there after maybe three weeks-
[patient] sure .
[doctor] . so we can take a further look .
[patient] okay . sure .
[doctor] but you should be fine-
[patient] yeah .
[doctor] . after just resting and regular pain reliever .
[patient] okay . all right .
[doctor] um-
[patient] should we take another x-ray when i come back , if the pain does n't improve ?
[doctor] um , maybe . let's see how you're doing in the next three weeks .
[patient] uh .
[doctor] hey , Sarah . um , order medications and procedures as discussed . all right .
[patient] okay .
[doctor] um , i think that's good for today . hope you feel better soon .
[patient] okay . thank you , doctor .
[doctor] yeah .
[patient] hopefully , the pain reliever , uh , ibuprofen actually helps .
[doctor] yeah .
[patient] yeah , and if i have more pain , can i call you ? can i fix up another appointment earlier than three weeks ?
[doctor] um , you can also try advil .
[patient] okay .
[doctor] yeah , so , um ...
[patient] yeah .
[doctor] ale- , aleve . i mean , aleve .
[patient] i see . okay , thank you , doctor .
[doctor] thank you . | CC:
Left shoulder pain.
HPI:
Ms. Anderson is a 44-year-old female who presents today for an evaluation of the left shoulder. She states that she was in gymnastics 1 week ago. The pain has been present since that time. She has pain with any type of movement of her left shoulder. She had taken Tylenol for 2 to 3 days with no improvement in her symptoms.
She has a surgical history significant for prior left upper extremity surgery.
EXAM
Examination of the left shoulder shows pain with range of motion.
RESULTS
X-rays of the left shoulder, 3 views obtained on today's visit show no obvious signs of fracture.
PLAN
At this point, I discussed the diagnosis and treatment options with the patient. I have recommended taking ibuprofen 600 mg three times per day for one week. If the patient does not have relief from the ibuprofen she will take Aleve. The patient may also utilize ice or heat packs. She should rest her left arm and may not lift or carry heavy objects with her left arm. The patient should follow up in three to four weeks if the pain persists. We may repeat the left shoulder x-ray at that time.
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D2N097 | virtassist | [doctor] elizabeth , how are you ?
[patient] i'm doing okay . how are you ?
[doctor] doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ?
[patient] okay .
[doctor] all right . elizabeth is a 66-year-old female with a past medical history of significant for depression and hypertension who presents for her annual exam . so elizabeth , it's been a year since i've seen you .
[patient] mm-hmm .
[doctor] how are you doing ?
[patient] i'm doing well . there's been so many events now that we've been able to get vaccinated , i've been able to see my grandkids again , go to more birthday parties , it's been fantastic .
[doctor] yeah , i know . i've ... i mean , we've had some communication over telehealth and that type of thing , but it's not the same as being in-person , so i'm happy to see you today . now tell me a little bit about , you know , we have n't really got a chance to talk about your depression . how are you ... how are you doing with that ? i know we have n't had you on medication in the past because you're on medication for other things . what are your strategies with dealing with it ?
[patient] so i've been going to therapy once a week for the past year . um , mostly virtually , um , but starting to get in-person . virtual was a bit of a struggle , but i feel like being in-person with someone really helps me .
[doctor] okay . and do y- do you have a good support system at home ?
[patient] yes , i do . i have my husband and , uh , my kids are right down the street from me , so i'm very lucky .
[doctor] okay . all right . so that's good to hear .
[doctor] how about your blood pressure ? did you buy the blood pressure cuff that i-
[patient] yes .
[doctor] . told you to ? okay . i know that we've been in communication and your blood pressures have been running okay . the last time i spoke with you , how are they doing since we last spoke ?
[patient] they've been doing well . i've been using the cuff , um , once a day , and they seem pretty normal .
[doctor] okay . and are you taking the lisinopril that i prescribed ?
[patient] yes .
[doctor] okay . great . all right . so i know that you did a review of systems sheet with the nurse when you checked in . you know , i know that you were talking about some nasal congestion . do you have any other symptoms , chest pain , shortness of breath , abdominal pain , nausea or vomiting , anything like that ?
[patient] no .
[doctor] no ? okay . all right . well , i wan na go ahead and do a quick physical exam , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the vital signs . so here in the office , you know , your blood pressure looks really good , as does your heart rate . so you are doing a good job managing your blood pressure . so i'm gon na take a listen to your heart and lungs , okay ?
[patient] okay .
[doctor] okay . so on physical examination , i do n't appreciate any carotid bruits in your neck . on your heart exam i do notice a slight 2/6 systolic ejection murmur , which we've heard in the past , so i think that's stable . your lungs in- are nice and clear , and you have some trace lower extremity edema bilaterally , so all that means is , you know , i agree , you know , maybe we should watch your diet a little bit better , okay ? but i wan na take a look at some of your results , okay ?
[patient] okay .
[doctor] all right . hey , Sarah , show me the ekg . and the nurses did an ekg before you came in , and that looks perfectly fine , okay ? so i wan na just go ahead and talk a little about your assessment and my plan for you . so for your first problem , your depression , i think you're doing a really good job with your strategies . i do n't think ... it does n't sound to me like i need to start you on any medication at this time , unless you feel differently .
[patient] no , i'm , i'm , good in that department .
[doctor] for your second problem , your high blood pressure , i agree , everything looks fine here now . i wan na just continue on the lisinopril , 20 milligrams a day . and i want you to continue to watch your blood pressures as well , and if they start rising , i want you to contact me , okay ?
[patient] okay .
[doctor] and for your third problem , for an annual exam maintenance , you know , you're due for a mammogram , so we'll go ahead and schedule that , okay ?
[patient] all right .
[doctor] all right . do you have any questions ?
[patient] um , can i take all my medicine at the same time ? does it matter ?
[doctor] yeah . you can set an alarm so that it reminds you to take your medication . but yeah , you can , you can take them altogether .
[patient] okay .
[doctor] all right . hey , Sarah , finalize the note . | CHIEF COMPLAINT
Annual exam.
HISTORY OF PRESENT ILLNESS
Elizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension, who presents for her annual exam. It has been a year since I last saw the patient.
The patient reports that she is doing well. She has been to multiple events now that she has been able to get vaccinated for COVID-19. She reports that she has been able to see her grandchildren again and attend birthday parties.
Regarding her depression, she has been going to therapy once a week for the past year. She reports that she is starting to go in person rather than virtual, which has helped even more. The patient has a good support system at home with her husband and her children live down the street.
The patient reports that her blood pressure has been doing well. She has been using the blood pressure cuff once a day and her readings seem normal. She has continued to utilize Lisinopril 20 mg daily, as prescribed.
The patient endorses nasal congestion. She denies any other symptoms of chest pain, shortness of breath, abdominal pain, nausea, or vomiting.
REVIEW OF SYSTEMS
• Ears, Nose, Mouth and Throat: Endorses nasal congestion.
• Cardiovascular: Denies chest pain or dyspnea.
• Respiratory: Denies shortness of breath.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Neck: No carotid bruits appreciable.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Slight 2/6 systolic ejection murmur, stable.
• Musculoskeletal: Trace lower extremity edema bilaterally.
RESULTS
Electrocardiogram stable in comparison to last year.
ASSESSMENT AND PLAN
Elizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension. She presents today for her annual exam.
Depression.
• Medical Reasoning: She is doing well with weekly therapy. She also has a solid support system at home.
• Medical Treatment: Continue with therapy and current management strategies. We will defer medication at this time.
Hypertension.
• Medical Reasoning: This is well controlled based on daily home monitoring. She has been compliant with lisinopril.
• Medical Treatment: Continue lisinopril 20 mg daily.
• Patient Education and Counseling: I advised her to continue with daily home monitoring of her blood pressures. She will contact me via the patient portal for any elevation in these readings.
Healthcare maintenance.
• Medical Reasoning: She is due for her annual mammogram.
• Additional Testing: We will order a mammogram for her.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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D2N098 | virtscribe | [doctor] all right . today i am seeing jose james . uh , date of birth 9/29/1957 . mr . james is a new patient who's having pain in his left shoulder and elbow . he fell five months ago going up a stairs , and the pain has been present since .
[doctor] hi mr . james , i'm doctor isabella . how are you doing ?
[patient] i'm okay . thank you .
[doctor] that's good . that's good . tell me what's brings you in today .
[patient] sure . so i've been having constant pain in my left shoulder and left elbow for a while , about five months or so . hurts all the time . pretty bad at times .
[doctor] mm . that does not sound like fun . it sounds like you injured it going up the stairs ?
[patient] yes , that's correct . it was icy , and i have to walk up a flight of stairs to my house . i stepped and my feet just went out . fell on my left side . seems like my shoulder and wrist took the brunt . it's been hurting since .
[doctor] yeah , that does seem like a likely cause of your symptoms . anything seem to make the pain worse ?
[patient] well , i've always hit the gym and lifted weights . i've been trying to keep with my routine of two days a week , but it's been hard . the pain is worse when i lift , and i have n't been able to lift more than 15 or 20 pounds which is very frustrating .
[doctor] mm-hmm . i can imagine it is when you're so accustomed to your routine .
[patient] exactly . i really enjoy my exercise , but over the past one to two weeks , i've stopped hitting the gym because the pain just was n't worth it honestly . i do keep up with my walking , though . my wife and i walk about 30 minutes almost every day . we have done this since i retired from my office job last year .
[doctor] i do not blame you , mr . james . does anything seem to help the pain that you've tried ?
[patient] not too much . i have iced a bit , but i have not taken anything for the pain . stopping exercise and some ice has helped a bit , but it still hurts enough for me to come to see you .
[doctor] yeah , okay . how about any numbness or tingling ? have you felt that at any point ?
[patient] no , doc . just pain . no tingling or numbless , numbness , thankfully .
[doctor] understood . understood . all right . well , let's go ahead and take a look and see what's going on .
[patient] sounds good . thank you .
[doctor] okay . use my general physical exam template . mr . james , i'm going to gently press around your shoulder and elbow here to see where your pain might be stemming from . just let me know when it hurts .
[patient] okay . it hurts when you press there on my elbow and here on my shoulder .
[doctor] okay . left shoulder and elbow , tender sa space , no warmth , erythema or deformity . positive hawkins-kennedy and neer's test . normal proximal and distar , distal upper extremity strength . intact median radial ulnar sensation and abduction to 90 degrees . normal empty tan , can test . okay , mr . james , w-what i think you are dealing with is impingement syndrome of your left shoulder . i do n't think there's an additional injury or issue with your wrist , but because everything is connected , you're experiencing pain in your wrist because of your shoulder . we do see this type of issue when someone has a fall , so it's good you came to see us , you came in to see us so we could help .
[patient] so what are the possible treatments ?
[doctor] well , we have a few options you can try . first option would be to start with physical therapy . i would recommend two sessions per week as well as any other exercises they give you to do at home . we can start there and if that does n't improve your pain , then we could try a cortisone injection .
[patient] i like the idea of starting with the physical therapy and have a next step if it does n't help . i am not opposed to a shot but would like to try the therapy first .
[doctor] all right . great . i'll get a referral order , and they will call you within the next day or two to get you scheduled .
[patient] okay .
[doctor] mm-hmm . also , please continue to ice , especially your shoulder , and rest as much as you can .
[patient] okay . i will .
[doctor] give us a call or email us if you have symptoms worsen , if your symptoms worsen or do not improve with the therapy .
[patient] will do . thank you . i appreciate your help .
[doctor] you're welcome . have a great day .
[patient] you too .
[doctor] all right . assessment is impingement syndrome of left shoulder . plan discussed with patient . referral is requested for dr. martha rivera to be in physical therapy two days per week . | CHIEF COMPLAINT
Left shoulder and elbow pain.
HISTORY OF PRESENT ILLNESS
Mr. Jose James is a 64-year-old male who presents for left shoulder and elbow pain.
The patient reports falling on his hand while going up stairs 5 months ago and has been experiencing constant pain since. He admits he was continuing to complete strength training exercises at least 2 times per week, however, he was unable to lift more than 15-20 pounds due to the pain.
During the past 1-2 weeks, Mr. James has discontinued strength training activities. Additionally, he has iced the inflicted areas, denies taking any pain medications, and reports his pain has slightly improved but it is still rather constant. He denies tingling and numbness.
The patient walks 30-minutes most days of the week.
SOCIAL HISTORY
Retired last year, was an office worker.
PHYSICAL EXAM
Musculoskeletal
Left shoulder and elbow, tender subacromial space. No warmth, erythema, or deformity. Positive Hawkins-Kennedy and Neer’s test. Normal proximal and distal upper extremity strength. Intact median, radial, ulnar sensation. Abduction to 90 degrees. Normal empty can test.
ASSESSMENT
• Impingement syndrome of left shoulder
Jose is a 64-year-old male who was seen today for impingement syndrome of his left shoulder, likely related to a fall he incurred 5 months ago.
PLAN
Today I discussed conservative options for left shoulder impingement with the patient, who opted to try physical therapy 2 session per week. Cortisone injection was discussed as an option if the physical therapy does not successfully reduce his pain. Additionally, I recommended continued ice and rest.
INSTRUCTIONS
email, or call if symptoms worsen or do not resolve.
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D2N099 | virtscribe | [doctor] next patient is randy gutierrez . date of birth , 8/10/2020 . please use review of symptoms . all text to write . physical exam , auto text uri .
[doctor] hello , how are you doing today ?
[patient_guest] we're okay , thank you .
[doctor] that's good to hear . so , how many days has randy been feeling sick ?
[patient_guest] well , i would say it started around supper time last night .
[doctor] last night , okay , and what's been going on ?
[patient_guest] well , he started to get a runny nose .
[doctor] okay , and is he stuffy too ?
[patient_guest] yeah . yeah .
[doctor] okay , and have you noticed , is his mucous clear right now ?
[patient_guest] it is , it is right now , yes .
[doctor] okay . and , does he also have a cough ?
[patient_guest] yes , but it's not barky .
[doctor] and does he act like he has a sore throat or is he pulling on his ears ?
[patient_guest] well , i know he's been pulling on his ears , yeah .
[doctor] okay .
[patient_guest] you know , he also , he's also been going crazy rubbing at his nose too .
[doctor] okay . and , any fever you've noticed ?
[patient_guest] i checked his rectal temperature and it was 100.3 .
[doctor] okay . so , a little bit of a low-grade fever there , definitely . and , how was his appetite ? did he eat last night ?
[patient_guest] yes , he did . yeah .
[doctor] and how about this morning ? did he eat his breakfast ?
[patient_guest] uh , this morning he ate about seven ounces from the bottle .
[doctor] okay .
[patient_guest] and then he got another bottle , and he barely ate that . um , i offered him cereal and he would n't eat that either .
[doctor] okay .
[patient_guest] so , he varies i guess .
[doctor] how is his energy ? does he seem like he wants to take more naps , or does he have pretty good energy ?
[patient_guest] mmm , it seems like he's irritable .
[doctor] irritable because he is n't feeling good ?
[patient_guest] yeah . he is energetic , but it seems like he ca n't go to sleep , like , he's fighting it really hard .
[doctor] okay , and just for the chart , is there anyone , anybody else exposed to him who has been sick ?
[patient_guest] yes , his older sister's been sick .
[doctor] thank you .
[patient_guest] we also had a play date with my nephew , who i learned later had a sinus infection .
[doctor] and what medication have you tried for him ? anything at all ?
[patient_guest] um , i've been doing the saline mist in his nose .
[doctor] good , good . that's a good choice .
[patient_guest] i did give him tylenol really early this morning because he was warm when i took the sleeper off of him , and we had the ac on in the house , but his whole body was sweating .
[doctor] i see . and , any other medications ?
[patient_guest] we did put some baby vick's on his feet last night to try and help him breathe . and , i also used the humidifier .
[doctor] okay . that's good .
[patient_guest] okay . okay .
[doctor] so , there was another thing i wanted to bring up since we're here . it appears that his cradle cap has gotten a little worse . what are you using on it ?
[patient_guest] i've been using the cradle cap brush , and then i use regular aveno shampoo .
[doctor] is it a dandruff shampoo ?
[patient_guest] no , i do n't think so .
[doctor] okay , thank you . well , let's complete his exam and then we'll talk about the next steps .
[patient_guest] okay , sounds good .
[doctor] can you take a big breath randy .
[patient_guest] where's mama ?
[doctor] do n't forget to breathe little one . okay . let's try the front too .
[patient_guest] yeah , it's okay buddy .
[doctor] excellent . he's doing excellent . next let's- let's check out those ears .
[patient_guest] okay .
[doctor] let's try to make sure you do n't tip all the way over .
[patient_guest] dino , you're doing so good .
[doctor] all right . ears look okay . we're going to slide you forward so you do n't bump your head when i lay you down .
[patient_guest] hey , you're- hey you're okay . you're okay .
[doctor] okay , you can go ahead and sit him back up if you like .
[patient_guest] all right . thank you .
[doctor] all right . so , he's just kind of getting started with this , and i think we're seeing something viral right now . often sinus infections will start out as a virus and then will become bacterial infections if left alone and does n't go away . but , i do n't think he needs any antibiotics , at least not at this point in time . um , keep up with the fluids , rest , and i would watch him very carefully for a barking cough . if he does get a barky cough , then that tends to be a little bit more significant and a little more severe . so , if he develops a barky cough , i want you to give him a half a teaspoon of his sister's medicine .
[doctor] you know , i'm almost tempted to give you some of the medicine because they're probably sharing the same virus .
[patient_guest] okay .
[doctor] actually , i will . i'll go ahead and just give you some as well .
[patient_guest] okay . okay .
[doctor] but , if he does n't become barky , you do n't have to use it . it only works for the barky cough .
[patient_guest] mm-hmm , got it .
[doctor] okay . we'll do the same thing with him , as long as nothing gets worse , and we'll see him back in one week . so , it wo n't get rid of a regular cough . he can use zarbee's , but use the dose for kids under a year of age . so , if you wan na get some of that , you can definitely try that for him , it can help out a little bit with the regular cough .
[patient_guest] i do have a question . do you or do you not give honey to babies ?
[doctor] yes , that's a great question . you do n't give honey to kids under a year , instead , you can give them agave , which is a different type of nectar . um , now you can give honey to his older sister , that is okay , but for him , it would not be very good because his stomach acid's not good enough to break down the botulism spores . so , it'd cause him harm . um , you should look at the package of say , honey nut cheerios . it says right on there to not give it to a baby .
[patient_guest] okay .
[doctor] now , whether that would really hurt a baby , i am unsure , but it has real honey in it . so , no honey for him , but agave is definitely fine .
[patient_guest] okay . so , zarbee's for the stuffy nose .
[doctor] yes , zarbee's .
[patient_guest] and then you said , uh , which medicine to give him just in case ?
[doctor] i'm gon na give him the same medicine as his sister , and just hang onto it , um , just to watch and see . if this was a monday and we had a whole week to watch , i would say to just call us if things got worse , um , but since , um , if it's gon na be the weekend , and things might worsen tonight or tomorrow night , i'd rather you have just what you need on hand .
[patient_guest] okay .
[doctor] right , does that make sense ?
[patient_guest] yeah , yeah . that makes sense .
[doctor] okay , great . and that way you do n't have to share , um , with his sister .
[patient_guest] right , okay .
[doctor] and since he's about half her size , we'll do half the dose , which is a half a teaspoon .
[patient_guest] okay . will this information all be in the papers ?
[doctor] yes . and so , if he ends up starting the medicine , just give him a half a teaspoon for five days .
[patient_guest] okay .
[doctor] yeah , that's the only thing it wo n't say is , " as needed , " or anything like that .
[patient_guest] mm-hmm , understood , thank you .
[doctor] you're welcome .
[patient_guest] and the cradle cap ?
[doctor] what i would do is use something like either head & shoulder's , or selsun blue , or nizoral ad . now , do n't get the extra strength stuff , just use the regular strength . um , cradle cap , it's just basically a fancy way of saying dandruff . so , those shampoos will help get rid of it . it's not an immediate thing 'cause they , um , they are all dead scales , and you still have to brush them off . so , continue to use the soft brush and some baby oil , or something that will help get the scales out , and those shampoos will actually help to prevent it as well . use it two times per week , not every day , but maybe twice a week .
[doctor] so , two days between shampooing , use what you normally use any other time . and then , often , within six weeks or so , you'll notice that the-the cradle cap is just , um , not coming back anymore . but , he has to be careful because it's not ph balanced for eyes . so , just make sure when you're rinsing his hair you avoid his eyes .
[patient_guest] okay . okay .
[doctor] all right . and , if it keeps getting worse , definitely let us know .
[patient_guest] okay . sounds good .
[doctor] good . and , since they do n't have covid-19 , you can go right ahead and check out .
[patient_guest] okay . and both appointments in the week ?
[doctor] correct . we'll see you all then . bye randy , feel better .
[patient_guest] all right , great . thank you so much .
[doctor] you are welcome , and have a good rest of your day . | CHIEF COMPLAINT
Cough, nasal congestion, and rhinorrhea.
HISTORY OF PRESENT ILLNESS
Randy Gutierrez is a 9-month-old male who is being evaluated today for a cough, nasal congestion, and rhinorrhea. He is accompanied by his mother.
Symptoms began yesterday around dinnertime with clear nasal drainage, pulling on his ears bilaterally, and rubbing his nose frequently. He does not have a barky cough or a sore throat. His rectal temperature was 100.3 degrees. The patient did consume a 7 ounce bottle this morning, but mostly denied the next offered bottle and declined cereal. He is irritable and having trouble falling asleep, described “like he is fighting it”.
The patient has been exposed to an older sister who is sick and a cousin who has a sinus infection.
Treatment has included saline nasal spray, Tylenol, baby Vick's, and a humidifier. When the patient aroused this morning, he was warm to the touch. When his sleeper was removed, he was quite sweaty despite the air conditioner being on.
The patient's dandruff is also worsening. The only tried treatment is Aveeno shampoo.
SOCIAL HISTORY
Older sister.
CURRENT MEDICATIONS
Tylenol PRN.
PHYSICAL EXAM
Temperature 100.3 degrees.
Ears, Eyes, Nose, Throat
Nasal congestion, clear mucus, rhinorrhea. Bilateral pulling of ears, no sore throat or hoarseness.
Respiratory
Positive for cough.
ASSESSMENT
• Viral infection
• Dandruff
PLAN
Viral infection
The patient presents with a viral infection and does not need antibiotics currently. I advised continuation of fluids, rest. Additionally, I suggested trying Zarbee’s for children under 1 years old. If a croup cough develops, the patient will receive a 0.5 teaspoon.
I also provided counseling to the mother to avoid giving honey to the patient for his first year of life due to botulism spores.
Dandruff
The patient is experiencing worsening symptoms of dandruff. I recommended Head and Shoulders shampoo, Selsun Blue, or Nizoral A-D 2 times per week, combined with his usual shampoo. I counseled the mother that she should be careful not to get the shampoo in the patient eyes and to not use the extra strength shampoos. Additionally, he may also use baby oil and a soft brush on the area.
INSTRUCTIONS
Return in one week for a re-check.
|
D2N100 | virtscribe | [doctor] kayla ward , date of birth , 4/28/07 . mrn 3-8-4-9-2-0 . she's here for a new visit with her mother for acne located on the face , which started about two years ago and is present most every day . she has been using persa-gel and washing regularly , which is somewhat helpful . there are no associated symptoms including itching , bleeding , or pain . no additional past medical history . she lives with her parents and sister . they have a dog , bird , and bunnies . she is in 7th grade . she plays basketball and volleyball and tap . she wears sunscreen in the summer , spf 30 . no additional family history . hi kayla , i'm dr. juan price . i hear you are starting to get some acne on the face . how about the chest and back ?
[patient] it's not too bad .
[doctor] so , it's not bad on the chest or back . you've used some over the counter items like washes and persa-gel ?
[patient] yeah .
[doctor] do those seem to be helping ?
[patient] yes , i think so , a little bit .
[doctor] good . what's your skin care routine like now ?
[patient] do you wan na know , like , the things i currently use ?
[doctor] yes . what do you do for your acne in the morning ? and then what do you do at nighttime ?
[patient] i wash my face , more like i wipe it down in the morning . then at night i use an elf facial cleanser called the super clarity cleanser . i finish with a toner and then the persa-gel .
[doctor] when you say , " wipe your face in the morning , " do you use a product or just water ?
[patient] mm , just water and a washcloth , really . if i feel really greasy , sometimes i'll use the elf cleanser in the morning , too .
[doctor] okay . and is today a good day , bad day , or an average day for you ?
[patient] mm , i would say it's probably a good day for me , of course , since i'm here , right ?
[doctor] acne is always good when you come to see the doctor . do you find that your acne flares with your periods ?
[patient] no , not really .
[doctor] and do you get a regular period ?
[patient] yup .
[doctor] how long have you been getting a regular period ?
[patient] mm , i think about two years .
[doctor] okay .
[patient_guest] the biggest flare , probably , was when she started school sports in the fall , just with all the sweating .
[doctor] yup , that will do it . is there anything else that you've noticed , mrs. ward ?
[patient_guest] no . kayla really has been doing a good job with the facial care regimen . it just does n't seem to help as much as we wanted .
[doctor] got it . okay . well , let's take a look then . full exam is performed today , except for under the underwear and under the bra . multiple benign nevi on the trunk and extremities . scattered skin colored papules . open and closed comedones . and erythmateous papules on the face , primarily on the forehead and with also some on the central cheeks and chin . the chest and back are relatively spared . and the remainder of the examination is normal . so , what i'm seeing from your exam today is mild to moderate acne , mostly comodonal with small inflammatory component .
[patient] okay , so is there anything we can do to help it ?
[doctor] yes . i would like to start with a topical therapy first . every morning , you will wash your face with a mild cleanser then use a moisturizer labeled , " noncomedogenic , " with sunscreen spf 30 or higher . this means it wo n't clog your pores . now , in the evening , wash your face with the same cleanser and allow it to dry . apply adapalene , 0.1 % cream , in a thin layer to the areas you generally get acne . i want you to start off using this a few nights a week and slowly work up to using it every night . if it is ... excuse me , if it is very expensive or not covered by insurance , you can try different gel over the counter . you can follow that with clean and clear persa-gel in a thin layer , or where you generally get acne . and then a noncomedogenic moisturizer . you're atopic retinoid will cause some sensitivity , so you will need to wear sunscreen when you are outside . it may also cause some dryness or irritation .
[patient] okay , i can do that .
[doctor] you also have multiple benign moles on your arms , legs , back and abdomen . this means they all look normal with no worrisome features . we will see if you have any progress over the next six months and follow up at that time .
[patient] okay , that sounds good . thank you .
[doctor] do you have any questions for me ?
[patient] no , i do n't think so .
[doctor] okay . if you have questions or concerns before your next visit , please call the office .
[patient] thank you , doctor , we will . | CHIEF COMPLAINT
New acne evaluation.
HISTORY OF PRESENT ILLNESS
Kayla Ward is a 15-year-old female who presents for new patient evaluation of acne located on the face. She is accompanied by her mother today.
Kayla states her acne started approximately 2 years ago and it is present almost every day. The patient’s mother notes that the most significant acne flares started in the fall when she was playing school sports. It does not tend to flare with her periods. Kayla reports that today is a good day for her acne. She denies any significant acne present on the chest or back. There are no associated symptoms, including no itching, bleeding, or pain.
The patient has been washing her face regularly. Her acne regimen includes washing her face in the morning with Persa-Gel and at night e.l.f. SuperClarify Cleanser along with toner and Persa-Gel. This regimen is somewhat helpful. She wears sunscreen in the summer SPF 30.
SOCIAL HISTORY
Lives with parents and sister. They have a dog, bird, and rabbits in the home. She is in the 7th grade and active in basketball, volleyball, and tap dancing.
FAMILY HISTORY
No significant family medical history.
PHYSICAL EXAM
Integumentary
Full exam is performed today except for under the underwear and under the bra. There are multiple benign nevi on the trunk and extremities. Scattered skin-colored papules, open and closed comedones, and erythematous papules on the face, primarily on the forehead, with also some on the central cheeks and chin. The chest and back are relatively spared. The remainder of examination is normal.
ASSESSMENT
• Comedonal acne.
• Multiple benign melanocytic nevi of upper and lower extremities and trunk.
Kayla Ward is a 15-year-old female seen today for new acne evaluation. Full skin examination revealed mild to moderate comedonal acne with a small inflammatory component and multiple benign melanocytic nevi of upper and lower extremities and trunk.
PLAN
Comedonal acne.
We discussed the diagnosis, etiology, and treatment options. I recommend starting with topical therapy first. The patient was instructed to wash face every morning with a mild cleanser, then use a non-comedogenic moisturizer with sunscreen SPF 30 of higher. In the evening, wash face with same mild cleanser and allow to dry. Apply a thin layer of topical retinoid, Retin-A 0.1% gel, to acne prone areas. Start off using a few nights a week, slowly work up to using every night. If it is very expensive or not covered by insurance, you can try Differin gel over the counter. Your topical retinoid will cause sun sensitivity, so you will need to wear sunscreen when you are outside. It may also cause some dryness or irritation.
Multiple benign melanocytic nevi of upper and lower extremities and trunk.
Reassurance given moles are normal in appearance and have no concerning characteristics. Will continue to monitor for progression or changes in 6 months.
INSTRUCTIONS
Follow recommended cleaning regimen.
Start Retin-A 0.1% topical gel, apply to acne prone areas, titrate as instructed.
Follow up in 6 months.
|
D2N101 | virtscribe | [doctor] patient is julia jones , date of birth 5/16/1996 . she is a new breast reduction consult . hello , how are you doing today ? i'm dr. gonzalez . it's nice to meet you .
[patient] nice to meet you , ma'am . how are you ?
[doctor] i'm doing good , thank you . so you're here to discuss a breast reduction , correct ?
[patient] yes . that's right .
[doctor] okay . perfect . let me just get logged in , here . have you met with anyone before about a breast reduction ?
[patient] no , i have n't .
[doctor] okay . and how long have you been considering this ?
[patient] it's probably been about six or seven years . but i mean , it's always been in the back of my mind .
[doctor] well , i perform a lot of breast reduction surgeries , pretty much every week , so it is a very common procedure .
[patient] okay , that's reassuring .
[doctor] yeah . so what i wan na do first is just get a little bit of history about the sort of symptoms that you're having . and then i'll do a quick exam .
[patient] okay . that sounds good .
[doctor] and then we'll talk more about the surgery and what it entails . and , um , at this point , who is your insurance provider ?
[patient] i have blue cross blue shield . well , actually , my husband just accepted a new job , and i will be on his plan , uh , which i believe is not going to be blue cross , but it may be changing .
[doctor] okay . what we typically do when we do a breast reduction consult , i'll document your symptoms , symptoms , we'll take some pictures , then , um , they get sent to the insurance company . and what they'll do is decide whether it's approved , or medically necessary , or not . but we wan na make sure we send it to the right insurance . do you know when you'll be on the new plan ?
[patient] most likely july .
[doctor] okay . so we may just wait until july to submit for approval at that time .
[patient] okay .
[doctor] so regarding your symptoms , do you experience back pain ?
[patient] well , i've been going to the chiropractor for a few years . i do have a lotta pain here and here . but i do n't know if it's all from my breasts or not . it gets painful and builds up . so i think i could attribute it to my breasts , when i'm working at my desk all day .
[doctor] okay . and in your neck and your upper back . and how long has this been going on ? would you say five years , 10 years , or even since puberty ?
[patient] i would say since i was in high school .
[doctor] okay . and do you have the bra strap indentations in your shoulders ? um , i saw that you're wearing about a g cup .
[patient] yes . i do get indentations , but i do n't really wear a regular bra that often . i mostly were a 34 e sports bra because it's more comfortable . and the others are expensive in my size .
[doctor] yeah , i have heard that as well . and , um , have you had any children , or are you planning to have any children in the future ?
[patient] no , i do not have any kids now . but we might plan to in the future .
[doctor] okay . and at this time , are you experiencing any numbness or tingling in the s- in the hands or any nipple pain ?
[patient] sometimes , yes .
[doctor] okay . and rashes , do you get any rashes underneath your breasts ? and , and it could be from sweating .
[patient] no , but they are always sweaty .
[doctor] okay . and then do you feel like your activities are limited because of the size ?
[patient] there's certain things i do when i have to hold them , like working out and any jumping or running . and it hurts .
[doctor] and it hurts , okay . and , and you saw a chiropractor . but what about physical therapy for your back pain ? or do you take any pain medicine for it ?
[patient] y- no , but i do take a migraine medication , propranolol .
[doctor] that's okay . so let's see . i know that you have a history of breast cancer in your family . have you had any mammograms ? and how old was your mother when she had it ?
[patient] mom was 40 . and they recommended me starting at age 30 for mammogram . i'm still ... i mean , i'm 25 . so i'm still a little bit young .
[doctor] okay . and otherwise , it seems like you're really healthy ?
[patient] yes , for the most part . i lost about 10 pounds over the past few months , and i still would like to lose about 20 more pounds .
[doctor] congratulations . that's great . and then , um-
[patient] thank you .
[doctor] . so then ... you're welcome . and so do you use any tobacco , drugs , or alcohol ? and then , um , you said that you were going to school . what are you going to school for ?
[patient] uh , i drink a little wine on occasion , and for school , i'm currently studying psychology .
[doctor] okay , that's great . all right . so what we'll do is we'll go ahead and take a look . i'm gon na take a couple of measurements . and we'll kinda talk about the surgery afterwards . um , so go ahead and stand up for me , julia . okay . so , looking at the measurements , it looks like one breast is a little lower than the other .
[patient] yeah .
[doctor] okay . well , thank you so much . it looks like i have all the measurements that we need . you can go ahead and cover up now .
[patient] okay .
[doctor] so i think you're a great candidate for a breast reduction . when we talk about a breast reduction , what happens is that we remove the tissue out of the breast .
[patient] okay . that's fine .
[doctor] and we would then lift them and elevate the nipple position in order to help with your back pain , neck pain , and because i'm a plastic surgeon , of course i want them to look nice as well .
[patient] right .
[doctor] so typically , when you do the breast reduction , we make an incision around the nipple straight down and then underneath . and it kinda looks like , um , an anchor below . then straight down , and underneath , and through that incision , we're able to f- to lift the breast . and we'll take off any extra fat and breash- breast tissue . so that way it becomes smaller in size . and i noticed that you would like to be a b cup . so i do tell every patient we can make you as small as your blood supply allows . and what that means is we must move the nipple without cutting off any of its blood supply during the surgery .
[patient] okay . well , thank you for explaining that .
[doctor] you're welcome . and in your case , you'll probably be a small c. um , a b cup might be a little bit small , but we'll see once i'm doing the , the procedure for you .
[patient] okay .
[doctor] and typically the surgery takes about three hours . you will have drains , one in each side . and that helps prevent fluid from building up in the breast . and that stays in for about a week . and then we'll remove them in the clinic . and you'll have a clear plastic tape over your incision that should help with the scars . and , um , we've seen that patients who have lighter skin , the scars will tend to be red at first . and then it takes about a year for a scar to mature in line .
[patient] okay . well , i'm not too worried about the scars .
[doctor] okay . and i do like to keep patients overnight . it's just going to be for one night in the hospital . and we just wan na make sure your pain is controlled , make sure you're not nauseated , all of that stuff . some patients wan na go home that same day . but you know that some people get nauseated , and the last thing that i want is for you to be vomiting at home alone without the , the support here at the facility .
[patient] okay , yeah , that sounds good .
[doctor] okay . and then about 30 % of patients say that they can not breastfeed after a breast reduction , and the reason is the breast is made up of fat . and it's also made up of a gland . and the gland is what produces the milk .
[patient] okay .
[doctor] and so in order to reduce the size of the breast , we have to take out both the fat and the glands . so it just depends on how much is left , whether you can breastfeed in the future . and then also , the breast will change over time . if you , um , gain weight , they will get larger , things like that .
[patient] yeah , okay .
[doctor] and if you have children , they will change as well . they will enlarge , especially if you can breastfeed . but they'll go back down and will appear , um , a little bit deflated .
[patient] yeah . i do n't know if i'm interested in breastfeeding .
[doctor] okay . um , the hormones of pregnancy , though , will change the breasts , so that's just something to be aware of , and i tell all younger patients that .
[patient] okay , yeah . absolutely .
[doctor] and then typically nipple sensation is fine after a breast reduction , but there is a slight chance that you'll have an alteration in the nipple sensation or not have any sensation in the nipple . generally the nipple is just fine unless it is a massive reduction . and it's quite normal after surgery to be a little bit bruised , and then it just takes some time for that to go away .
[patient] yeah , okay .
[doctor] but other than that , you know , most patients are very happy after the breast reduction because the symptoms of the back pain , the neck pain , you can feel relief almost immediately . so do you have any questions , julia , about the process or anything like that ?
[patient] no , not really .
[doctor] okay . and , i do think you're a good candidate for it . and i think you'll benefit from it as well .
[patient] good . i look forward to a relief .
[doctor] i think you just have to do it when you are ready , when you know that you feel like it's a good time , because it is a commitment , and you will have some activity restrictions for about six weeks after surgery , uh , no heavy lifting . and i do say no driving for two to three weeks . and the drains stay in , like i said , for about a week .
[patient] okay . well , i am ready as soon as my insurance is switched over .
[doctor] okay . well , i think from this point , if you want to , we can take photos today , while you're here . i have all the documentation now in the note about your symptoms , and that's what the insurance company is going to look for . so thank you for answering those questions . so once we have the new provider , we'll go ahead and get that submitted . and then , when they approve it , um , what the office will do , is they'll work with you on a surgery date , and then we'll meet again right before the surgery to answer any last minute questions and go over the instructions in more detail , things like that .
[patient] okay . well , i will notify the office as soon as i have the insurance information .
[doctor] that sounds great . and then we can get it all in process . and it was so nice to meet you . and catherine will be right in to get your photos . julia jones is a 25 year old female with symptomatic macromastia , presenting for evaluation of breast reduction . the patient has attempted nonsurgical treatments , but the minimal relief , and is an ideal candidate for bilateral reduction mammoplasty . her minimum required resection , based on a bsa of 2.65 , with the schnur scale is 1,792 grams , which should be attainable . given her extremely large breasts and the measurements above , there is potential for using a nipple graft .
[doctor] physical exam findings of breast , inspection reveals asymmetrical breasts with severe ptosis bilaterally . there is no nipple retraction or discharge bilaterally . no breast tenderness , masses , or axillary lymphadenopathy is palpable . | CHIEF COMPLAINT
Macromastia.
HISTORY OF PRESENT ILLNESS
Julia Jones is a 25-year-old female who presents for evaluation of macromastia.
Ms. Jones reports this is her first visit in regard to a breast reduction and has been interested in getting a breast reduction for approximately 7 years. Currently she has Blue Cross Blue Shield insurance but will be added to her spouse’s insurance plan in 07/2021.
Current breast size is a G cup, although she primarily wears a 34 E sports bra for comfort, and desired breast size is a B or C cup. No prior pregnancies, potentially planning on pregnancies in the future, and unsure of breast feeding.
The patient endorses back and neck pain since she was in high school. Her back and neck pain has been managed by a chiropractor for a few years. She reports weight loss of 10 pounds over the past few months and would like to lose an additional 20 pounds.
She endorses the following symptoms because of her macromastia for 7 years:
Chronic upper back pain: Yes.
Bra strap grooving in shoulders or indentation on lateral chest wall: Occasionally.
Neck pain: Yes.
Nipple pain or numbness: Yes.
Paresthesia of the hands or arms: Yes.
Intertrigo, rash or yeast or other skin problems beneath breasts: Yes, persistent sweating.
Stooped posture: Yes.
Physical activity limited by breast size: Yes.
The patient has undergone the following therapies:
Physical therapy: No.
Special bras: Yes.
Non-narcotic pain medication: No.
Narcotic pain medication: No.
Her previous breast surgery includes:
Previous reconstruction: No.
PAST HISTORY
Medical
Significant for migraine headaches.
FAMILY HISTORY
Mother with prior history of breast cancer at age 40.
SOCIAL HISTORY
Tobacco: No prior history.
Alcohol: Socially. One glass per week.
Drug: No prior history.
Occupational and Educational: Currently studying to be a psychologist.
CURRENT MEDICATIONS
Propranolol for migraine prevention.
VITALS
BSA 2.65
PHYSICAL EXAM
Breasts
Inspection reveals asymmetrical breasts with severe ptosis bilaterally. There is no nipple retraction or discharge bilaterally. No breast tenderness, masses, or axillary lymphadenopathy is palpable.
ASSESSMENT
• Macromastia.
Julia Jones is a 25-year-old female with symptomatic macromastia presenting for evaluation of breast reduction. The patient has attempted non-surgical treatments with minimal relief and is an ideal candidate for bilateral reduction mammoplasty. Her minimum required resection based on a BSA of 2.65 with the Schnur scale is 1792 g, which should be attainable. Given her extremely large breasts and the measurements above, there is potential for using a free nipple graft.
PLAN
An extensive discussion of breast reduction surgery was performed with the patient with consideration of the patient's age, co-morbidities, previous surgical history, body habitus, BMI, and smoking history. Surgical time, immediate recovery course, and longer term recovery course were discussed. Relief of the patient's current symptoms related to macromastia was not guaranteed though is expected to improve. Specific breast size was discussed, also not guaranteed. I explained the expected outcomes of using a free nipple graft such as an insensate nipple and an inability to breast feed. The patient understands that the decision for a free nipple graft will be made intraoperatively based on assessment of nipple perfusion.
Risks and benefits of were discussed with the patient The patient understands the above risks, benefits and alternatives to surgery and wishes to proceed with bilateral reduction mammaplasty.
The patient will be switching to a different insurance policy in 07/2021. Once we get the new insurance information from the patient, we will submit it to her insurance company. If approved, she will return for preoperative counseling and consent.
Return to clinic prior to scheduled surgery date for preoperative counseling and consent. |
D2N102 | virtscribe | [doctor] kelly wood . date of birth , february 15th , 1979 . established patient here for renal ultrasound because of hematuria . urine dipstick today . negative for leukocytes , nitrates , protein , ketone , bilirubin and glucose . color yellow and clear , urobilinogen 0.2 , ph 5.5 and specific gravity 1.020 . there is a trace amount of blood in the urine and intact . renal ultrasound impression . right kidney is 10 cm in length by five centimeter wide . there are no stones , masses or hydronephrosis . the left kidney is 10.8 centimeters in length and five centimeters wide . there is a six millimeter left renal stone non-obstructing . 533 milliliters pre-void and 0 milliliters post-void . hi , mrs. wood . i see you're just finished your ultrasound .
[patient] yes , ma'am .
[doctor] well , it looks like you have one stone in the left kidney but it's not obstructing anything .
[patient] i knew it had to be a kidney stone . i passed what looked like two small stones last week after i scheduled this appointment . and then for the past six weeks , i've had a few episodes of bright red urine the color of , like , cherry kool-aid . and last week , i was constantly having to pee and it hurt something terrible .
[doctor] how bad was your pain on a scale of zero to 10 ? zero being no pain and 10 being worse , as you can imagine .
[patient] um , at the time , i'd say an eight .
[doctor] are you having any flank pain now or tenderness in your lower back ?
[patient] no , after passing those stones , things have felt a lot better .
[doctor] that's good to hear . now , it looks like you're only taking alavert 10 milligrams a day and have no drug allergies . is that correct ?
[patient] that's right .
[doctor] all right , let's take a look at you today . let's use my default pe . well , mrs. wood , we know that the blood in your urine was due to the kidney stones . fortunately , you passed two last week and the blood has nearly subsided . you do still have one stone in the left kidney . since it's not obstructing or causing pain , i do n't recommend any surgical intervention at this time .
[patient] i'd like to know what i can do to stop getting these stones .
[doctor] as we discussed last time , the formation of kidney stones can not be attributed to a particular cause . but several factors increase the risk , such as dehydration , family history , certain foods , digestive tract disease and certain medical conditions .
[patient] yeah , i know i do n't drink near the amount of water that i should . i drink more mountain dew than anything .
[doctor] you should drink about half of your body weight in ounces of water a day .
[patient] so , if i weight 250 pounds , i should drink ?
[doctor] that would be 125 ounces of water a day and you should avoid drinking sugary drinks like mountain dew .
[patient] okay . is there any food i should n't eat ?
[doctor] great question . you should avoid food rich in sodium oxalate and animal protein . so that would be salty , processed food because they're high in sodium . ideally , you should consume less than 1,000 milligrams of sodium a day and reduce the amount of beef , poultry , fish , and pork .
[patient] what's oxalate ?
[doctor] it's an organic acid found in plants , that when digested , it binds to minerals that stones are formed from . foods like spinach , chocolate , beets , rhubarb and soy products .
[patient] well , i'll do whatever it takes to try to avoid getting these stones again .
[doctor] great . and here's a handout that you can look over . it goes over the dietary recommendations and what to avoid .
[patient] okay , good . i like to have things in writing to help me remember .
[doctor] perfect . well , if you have any more questions . if you do n't have any more questions , you're all set . i wo n't need to see you back until next year , as long as you do n't have any more issues like bleeding or pain . if you do have any issues , you can always call the office sooner . and if you experience any severe pain or bright red blood in your urine , you should go to the emergency room .
[patient] all right . well , let's hope we do n't have to do either of those and i see you next year .
[doctor] yes , let's hope . come right this way and i'll walk you to check out . update pe abdomen . no flank pain . anti gu . normal vaginal exam . primary diagnosis is hematuria . secondary diagnosis is chronic urol ... urolithiasis . thank you . this completes mrs. wood encounter . | CHIEF COMPLAINT
Hematuria.
Chronic urolithiasis.
HISTORY OF PRESENT ILLNESS
Mrs. Kelly Wood is a 41-year-old female established patient with chronic urolithiasis who returns in follow up for renal ultrasound due to hematuria.
The patient reports having intermittent episodes of gross hematuria over the past several months. she states she had multiple voids in one day where the color of her urine was like cherry Kool-Aid last week; then passed 2 small stone like structures. Pain at the time was 8 out of 10 on a scale of 10. she currently denies any flank pain.
CURRENT MEDICATIONS
Alavert 10 mg tablet once daily.
ALLERGIES
No known drug allergies.
PHYSICAL EXAM
Genitourinary: Normal vaginal exam.
RESULTS
Renal Ultrasound
Impression: Right kidney is 10 cm in length by 5 cm wide. There are no stones, masses, or hydronephrosis. The left kidney is 10.8 cm in length and 5 cm wide. There is a 6 mm left renal stone, non-obstructing. 533 ml pre void and 0 ml post void.
Urine Dipstick without Micro
Color: Yellow.
Appearance: Clear.
Leukocytes: Negative.
Nitrate: Negative.
Urobilinogen: 0.2 EU/dL.
Protein: Negative.
pH: 5.5
Blood: Trace, intact.
Specific gravity: 1.020
Ketone: Negative.
Bilirubin: Negative.
Glucose: Negative.
ASSESSMENT
• Hematuria.
• Chronic urolithiasis.
Mrs. Wood presents today for renal ultrasound. The patient has had recurrent episodes of hematuria over the past few months secondary to chronic urolithiasis. Mrs. Wood reports passing two small stone like structures last week. Urinalysis today was notable for only a trace amount of blood and the renal ultrasound revealed a 6 mm non-obstructing renal stone in the left kidney.
PLAN
No surgical intervention is recommended, and the patient would like to discuss urolithiasis prevention. We had a very lengthy discussion with regards to urolithiasis formation and treating the underlying cause to prevent reoccurrence and associated potential dietary factors that could be involved with urolithiasis formation.
It is recommended that the patient maintain a healthy diet; limit salt, and animal protein. she should increase fluid consumption; adequate intake is half of her body weight in ounces of water daily and avoid sugary drinks. A copy of the dietary recommendations and avoidances was provided to the patient for reference. We will continue to monitor annually with renal ultrasound unless new symptoms develop. The patient voiced understanding and agreed with the recommended medical treatment plan.
INSTRUCTIONS
Follow up in 1 year with renal ultrasound, sooner should symptoms arise. Should you develop sudden onset of severe pain or gross hematuria go to the emergency room.
|
D2N103 | virtscribe | [doctor] next patient is melissa sanchez . date of birth , 9/23/1962 . mrn : 5484367 . she is being seen in office today for status post mitral valve repair done on 8/3/2020 . at her previous follow-up on 9/17 , we felt that she was doing quite well from a cardiac standpoint , and so we recommended she continue with the same medication . ecg taken on 12/26/2020 reveals atrial fibrillation with a controlled ventricular response . t-wave inversion anteriorly . compared to the previous study , there are no significant changes , and please add in the history , patient has a history of mitral regurgitation and atrial fibrillation , history of diabetes , asthma , and recurrent chest discomfort with negative cardiac workup for coronary artery disease .
[doctor] ms. sanchez , it's good to see you again .
[patient] yeah , it's good seeing you too dr. hughes . you look like you're doing well .
[doctor] i am , thank you . you too . you're looking great . how have you been feeling ?
[patient] pretty good . i'm definitely feeling better , thank goodness . i was having a rough time before surgery , um , but i think i'm overall pretty good now though .
[doctor] okay . well , that's really good to hear . i'm glad . are you having any new symptoms right now ?
[patient] no , not really . but , you know , i'm still getting some chest pains sometimes , and my breathing gets shallow . but , i guess i'm learning what i can and ca n't do . uh , so if i feel like that , if i'm , like , exerting myself , i slow down a bit which helps , and then when i go back to it later , i can usually finish whatever i was doing .
[doctor] okay . so , it does go away though ? how long does an episode seem to last ?
[patient] uh , only a few minutes i guess . then it disappears for a while . it's weird .
[doctor] what is a while ?
[patient] it goes away for a couple weeks . um , so when it happens , i just take the day nice and slow , i do n't push myself .
[doctor] okay . so , maybe it's a couple times a month you feel this way ?
[patient] yeah , just often enough for me to notice .
[doctor] understood . okay . are you taking your medications regularly ?
[patient] uh- . i've been trying to keep up with that . there's a lot of extra pills now , but i have a reminder app , so i do pretty well .
[doctor] okay . that's great . and so , you're taking coumadin , right ?
[patient] yeah , also lasix and the atenolol .
[doctor] are you having any side effects from the medications at all ?
[patient] not really . uh , i notice that the atenolol is making me irritable in the beginning , but i guess i've gotten used to it , does n't seem to bother me as much now .
[doctor] okay . well , that sounds good . sounds like you're well on the mend . so , why do n't i start out , um , with the physical exam , and just check you out .
[patient] okay .
[doctor] you're going to hear me describe things in detail or repeat things as i go to reference later for my notes .
[patient] okay .
[doctor] okay then . i'm going to be using my status post template , ms. sanchez , please lie down on the table here and we'll get started . all right . can you turn your head to the left . head and neck no jvd detected . you can turn back now and just take a couple of deep breaths for me please . okay , that's good . and lungs have reduced breath , but auscultation and percussion are clear . okay . breath normally , i'm just going to listen to your heart . rhythm is irregularly irregular .
[patient] that's a funny statement . what does that mean ?
[doctor] yeah , it does sounds kind of weird , right ? it's when your heart does n't beat with the correct rhythm , and whatever rhythm it does n't have a pattern to it . so , it's part of the atrial fibrillation .
[patient] wow , that sounds like a mess .
[doctor] yeah , it's not ideal . but , many people have a-fib are able to keep it under control with medicine and lifestyle changes .
[patient] agh , i see . that's good to know .
[doctor] okay . so , s1 slightly accentuated , no s3 . i'm going to touch your belly , and does any of that hurt .
[patient] nope .
[doctor] how about there ? and your feet ?
[patient] no , not really .
[doctor] okay , great . and trace peripheral edema on extremities . all right ms. sanchez , you can sit up now . so , it looks like your heart valves are working well and you are recovering from the surgery nicely .
[patient] good .
[doctor] yes . we are , we looked at your ecg taken earlier today , and we are seeing the a-fib , but it's being well controlled with the medicine , and you're taking coumadin , four milligrams , lasix at four milligrams a day , and the atenolol , you're taking that every day as well , right ?
[patient] yes . the 50 milligrams every day .
[doctor] great . it sounds like you're well on your way to recovery .
[patient] great .
[doctor] so , let's continue on your current meds . i'm glad that you're figuring out what your body can handle . definitely try to keep active as that will certainly help .
[patient] i'll do my best .
[doctor] and that's about it . do you have any questions for me ?
[patient] um , i do . when do i need to come back and get checked out ?
[doctor] well , i do n't think you need to come back soon . everything from a cardio perspective is fine . so , i think let's do a followup in about six to nine months .
[patient] all right , thank you . it was good to see you again dr. hughes .
[doctor] you as well ms. sanchez , do take care .
[patient] you too . | CHIEF COMPLAINT
Status post mitral valve repair.
HISTORY OF PRESENT ILLNESS
Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020.
On 09/17/20 we saw Mrs. Sanchez in office, and she was doing well and thus we recommended maintaining her current medications, she is using a reminder app to stay compliant with medications.
The patient reports feeling better and overall, pretty good. She denies experiencing new symptoms. She is still having chest pain intermittently, and her breathing “gets shallow” which results in her “slowing down” and decreasing her exertion. An episode of shortness of breath and chest pains may last a few minutes and will not recur for a few weeks.
PAST HISTORY
Medical
Mitral regurgitation.
Atrial fibrillation.
Diabetes Type II.
Asthma.
Surgical
Mitral valve repair 08/03/2020.
CURRENT MEDICATIONS
Coumadin 4 mg daily.
Lasix 40 mg daily.
Atenolol 50 mg daily.
PHYSICAL EXAM
Head and Neck
No JVD detected.
Respiratory
Lungs have reduced breath, but auscultation and percussion are clear.
Cardiovascular
Rhythm is irregularly irregular, S1 slightly accentuated, no S3.
Musculoskeletal
Trace peripheral edema on extremities.
RESULTS
ECG, 12/26/2020.
Impression: Atrial fibrillation with a controlled ventricular response, t-wave inversion anteriorly. Compared to the previous study, there are no significant changes. I also recommended that the patient continues to be active within her limits.
ASSESSMENT
• Status post mitral valve repair
Mrs. Melissa Sanchez is a 58-year-old female being seen today for a status post mitral valve repair, completed on 08/03/2020.
PLAN
Continue with current medications. Coumadin 4 mg daily, Lasix 40 mg daily, and Atenolol 50 mg daily.
INSTRUCTIONS
Return to clinic in 6-9 months. |
D2N104 | virtscribe | [doctor] judy gomez , mrn 869723 . date of birth , 5 , 7 , 1961 . she's in office today for ongoing management of psoriatic arthritis . hello , judy , how are you doing today ?
[patient] i'm doing good , thank you . how are you ?
[doctor] i'm great , thanks . so how have you been since the last time ? i know the last time we were talking about decreasing your prednisone dose , correct ?
[patient] yes . i'm just on one now and that seems to be enough .
[doctor] aw , that's great to hear .
[patient] yeah , there were a couple days there i took an extra one , just because there was a little extra pain in my feet . and i do have a desk job , so when i have a day off where i'm moving around a lot they do tend to hurt a bit more .
[doctor] okay . how many times did you do that ?
[patient] um , it was n't often , maybe once a week .
[doctor] okay . so it sounds like we're still on track for discontinuing the prednisone . we'll do that today and you can let me know how it goes on your next visit . and how about the methotrexate , do you think that helped with your joint pain ?
[patient] yeah , definitely . because i went to get my covid shots , um , but from the letter i got about it , it said that it could interfere with the vaccine , you know , reduce the efficacy . so i did n't take it on the week that i got the first shot .
[doctor] okay . and what happened ?
[patient] i felt absolutely horrible until i took it again a week later .
[doctor] i'm sorry to hear that . and- and what did you do about the second dose ?
[patient] well , i called into the hotline because i was in so much pain with the first one . and they said , " no , just go ahead and take it , " so i did .
[doctor] okay . that's good then . we do have to keep an eye out on it since it's a high-risk medication . do you have an appointment to get your blood drawn for the next time ?
[patient] no , they did n't give me one .
[doctor] okay . so we can do that for you too . uhm , so what questions do you have for me , judy ?
[patient] well , i just wanted to know why i was getting all these bruises here , so like when i bump myself . i do n't know where they're coming from .
[doctor] okay . that's probably from the prednisone , it can increase bruising .
[patient] okay . i did n't know that . um , i do n't even feel it when it happens , they just show up .
[doctor] yeah . unfortunately that can happen , but we're working on discontinuing that so let's see if the bruises do go away .
[patient] okay . that sounds good , thanks .
[doctor] okay , judy , please , um , sit up here and i'll take a look . shoes and socks off please .
[patient] all right .
[doctor] all right . let me see here . okay . so where is it hurting ? in your joints right here ?
[patient] yeah , a little . also in my feet joints as well .
[doctor] okay . and how about when you bend the knee like this ?
[patient] well , it hurt before we increased the methotrexate , but it's doing pretty good now .
[doctor] okay , good . can you flex your toes please ? good range of motion . also ridges in nails , that's from the psoriasis .
[patient] yeah . they've been like that for a long time now .
[doctor] okay . all right , uhm , ms gomez , it looks like we're moving along with your treatment nicely . we'll stop your prednisone and continue with the methotrexate . make sure to stop by the front desk and make an appointment for the blood work , and i'll see you in three months .
[patient] all right . it sounds good . thank you so much , it was great to see you .
[doctor] it was great seeing you too . thank you . | CHIEF COMPLAINT
Psoriatic arthritis management.
HISTORY OF PRESENT ILLNESS
Judy Gomez is a 61-year-old female who presents to the clinic today for ongoing management of psoriatic arthritis.
Ms. Gomez is currently taking methotrexate and prednisone 1 mg daily. She believes methotrexate has been relieving her joint pain.
The patient reports she has been doing well since her last visit. She has been able to decrease her prednisone dose to 1 mg daily; however, she took 2 mg for a couple of days due to increased pain in her bilateral feet.
The patient states when she received her first COVID-19 vaccine she held her methotrexate and felt "horrible" all week until the next Wednesday when she took it. She felt better by the end of the week. She did not hold methotrexate for her second COVID-19 vaccine.
PHYSICAL EXAM
Musculoskeletal: Full range of motion. Dystrophy of all the nails of the toes.
ASSESSMENT
• Psoriatic arthritis.
• High risk medication use.
PLAN
Psoriatic arthritis.
Stable on methotrexate and prednisone 1 mg daily. The patient will discontinue prednisone and continue methotrexate.
INSTRUCTIONS
The patient will follow up in 3 months.
|
D2N105 | virtscribe | [doctor] patient's name is diana scott . date of birth , 12/8/1920 . the date of service is 7/9/2021 . this is a new patient note .
[doctor] good afternoon . how are you today ?
[patient] i'm good , thank you .
[doctor] good . well , what brings you in to see me today ?
[patient] well , my doctor says that i have a heart murmur .
[doctor] okay .
[patient] so i do n't know how big a heart murmur i have , or really even what it is .
[doctor] okay . so how long have you had that for ? do you have any idea , or is that completely new as far as you know ?
[patient] yeah , she said it's a new worrisome heart murmur . so of course , i'm worried as well .
[doctor] got it . okay . and are you having any symptoms at all ?
[patient] i do n't think so . i do n't know what symptoms i should be having .
[doctor] okay . well , so you are 100 , so we ca n't really get around that one . so i expect that you probably do n't move quite as fast as maybe you used to ?
[patient] no , i definitely do n't .
[doctor] okay . and do you notice that you have any chest pain or f- feel shortness of breath ?
[patient] no , i do n't have any chest pain . um , my problem is i have severe pains in my legs , and so she had me going for a chest x-ray , and that was just last week .
[doctor] okay .
[patient] and so i started taking pain pills for my legs .
[doctor] okay , got it , for the legs . and do you feel short of breath at all ?
[patient] if i walk too fast or too long , or if i tried to drink a whole glass of water without stopping , then yeah , i do get short of breath that way .
[doctor] okay . and how far can you walk before you feel short of breath or sort of overly fatigued ?
[patient] well , i do have a walker now , so i do n't know . maybe when i walk to the end of the driveway or i walk around the culdesac .
[doctor] got it . all right .
[patient] so it is n't that bothersome to me at all . um , maybe more if i try to overdo it .
[doctor] okay .
[patient] then i , um , i get short of breath if i do overdo it though .
[doctor] okay , got it . and so how different would you say , um , that the symptoms are now compared to like six months ago or a year ago ?
[patient] i would say probably 70 to 80 % from about six months ago . before that i did n't notice anything at all .
[doctor] okay . so do you feel like it's mainly the leg pain that seems to limit you ?
[patient] my legs have been severe for about a month now .
[doctor] okay . and how about , do you feel lightheaded or dizzy at all ?
[patient] yeah . so i do take a pill for that when it does get bad .
[doctor] okay .
[patient] yeah , and i do n't take it every day , only when i do feel dizzy .
[doctor] okay . and so how about any passing out at all ?
[patient] no .
[doctor] okay , good . and how about irregular heartbeats ? do you ever feel like your heart is going too fast or like it skips a beat ?
[patient] i do n't notice it at all .
[doctor] okay , great . and how about any swelling in the legs at all ?
[patient] yeah , my ankles swell .
[doctor] okay . and how long has this been going on ?
[patient] um , i would say for probably six months . but it goes up and down , and sometimes it's worse than other times .
[doctor] okay . and how about any recent weight gain or anything else like that ?
[patient] um , i lost a little bit of weight , but i still weigh a 120 pounds , but i normally weigh about 130 pounds .
[doctor] mm-hmm . okay .
[patient] um , but that's been going down gradually for about a year .
[doctor] okay . and then how about any fevers , chills or anything else that's , that's going on that you can think of ?
[patient] no .
[doctor] good . so mainly it sounds like you came in , um , mostly because of the murmur . is that right ? and sort of just kind of seeing what things look like ?
[patient] yeah , that and i feel overly tired because i take all that medication .
[doctor] okay . and so fatigue as well . and have you ever had any testing of your heart done ?
[patient] i'm not really sure .
[doctor] okay . it does look like you've had a decent number of sh- , uh , surgeries here , ?
[patient] yeah , you name it .
[doctor] all right . well , i wo n't make you repeat them since i do have a good record . um , but just give me just a second and i'm going to enter the ones we need , okay ? all right . got them . and then , are you taking all the medicines that you went through with madison ?
[patient] yes .
[doctor] okay , good . and looking at your family history , it looks like maybe your brother had a heart attack . is that correct ?
[patient] it was actually my son , not my brother .
[doctor] okay , i'll make that adjustment .
[patient] um , but my brother did have a stroke . but that was because he had gotten sugar diabetes , and my eldest sister did have a heart problem as well .
[doctor] okay , i see .
[patient] yeah , so heart problems kinda run in the family .
[doctor] okay . all right . well , it looks like also that you never smoked . that's excellent . and then no allergies to medicines that you know of , is that correct ?
[patient] correct .
[doctor] all right . well , let's do a quick exam .
[patient] all right . sounds good .
[doctor] all right . well , for physical exam , please use the regular template . all right , please just breathe normally . great . and now take a few deep breaths for me . all right . do you feel okay ? are you feeling any dizziness or anything ?
[patient] no , i feel fine .
[doctor] okay , great . all right . well , that is it for the exam .
[patient] okay .
[doctor] all right . so what i'm thinking is , let's go ahead and schedule you for an echocardiogram . it's a very common test and it just takes a picture of your heart . and it'll let me see how well your heart is actually working .
[patient] okay .
[doctor] and i can order that for today . um , do you have time to complete that ? it should n't take too long .
[patient] yes , that's fine . i have time .
[doctor] okay , great . so we will complete that today , um , to assess your overall cardiac structure and function , as well as , uh , the valve view of where diseased .
[patient] okay .
[doctor] and some hospital outcomes and what we might suggest to fix that out , i'll go over that . so one possible suspicion i'm having is it's called , um , aortic stenosis , and that just means that one of your main valves of your heart has narrowed a bit and the valve does n't really open , um , quite fully . and this could just reduce or block the blood flow from your heart into the main artery of your body , and that's called the aorta , into the rest of your body .
[patient] okay .
[doctor] and if this is severe , then we might wan na perform a procedure called the transcatheter aortic valve replacement , or we just call it tavr . and it is a minimally invasive procedure to replace the valve .
[patient] well , i would have to think about that . i'm not too sure i'd wan na do that , given my age of all .
[doctor] yeah , sure , no problem . and we do n't have to make any decisions today , just , you know , wanted to go over a couple of these things . um , but sometimes we can also perform a surgical aortic valve replacement , or it's called an savr . but really , because of your age and medical history , um , unfortunately , that would n't be a good option for you .
[patient] i see . okay . well , i guess we'll see , um , what you see from , from the , um , test .
[doctor] yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently .
[patient] okay , good .
[doctor] and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able to stop your statin .
[patient] really ?
[doctor] yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin .
[patient] okay , that sounds great . thank you .
[doctor] you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them .
[patient] okay , i will .
[doctor] all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ?
[patient] not that i can think of . thank you so much . and i think it looks good .
[doctor] okay , awesome . all right . well , have a good rest of your day , and we'll see you soon .
[doctor] for physical exam , constitutional elderly otherwise no acute distress . cardiovascular normal s1 and s2 is preserved with a normal rate and regular rhythm . there is a 4/6 systolic murmur at the right upper sternal border with , uhm , mild radiation to the carotids . neurologic gait is normal for age .
[doctor] for assessment and plan , probably one cardiac murmur . diana has a 4/6 systolic murmur at the upper right sternal border with mild radiation to the carotids . this is most likely representative of aortic stenosis , for symptoms could be due to severe aortic , aortic stenosis . however , her s2 is relatively preserved , which would be more consistent with , consistent with moderate . some of her outside records do note diastolic dysfunction , so it is possible she , she did have an echocardiogram at some point in the past . she does not appear significantly volume overloaded today .
[doctor] her next problem is pvcs . her referral mentioned tachycardia . uh , her ekg today shows sinus rhythm with frequent pvcs , as well as an anterior septum infarct pattern . she does not have any significant palpitations and we will check an echocardiogram to assess overa- overall cardiac structure and function . depending on results as well as the severity of her aortic stenosis , we will need to consider an ischemic evaluation , or further , possibly a heart mon- monitor to assess overall burden of the pvcs . at this point , she's asymptomatic , so we will start with the echocardiogram only .
[doctor] her next problem , hypolipidemia , is managed by her pcp . due to bilateral leg pain over the last month , considered tavr evaluation following echocardiogram . statin could be indicated .
[doctor] and next problem , lightheadedness , dizziness . she is on meclizine for this . it is possible that some of her lightheadedness and dizziness is related to the aorta stenosis , and we will do an echocardiogram as noted above . pvcs on her ekg could be contributing , but she does not feel palpitations . we will consider a monitor , but start with the echocardiogram first as noted above . follow up three to four weeks after her echocardiogram is done to discuss results and next steps . end of dictation . | CHIEF COMPLAINT
Heart murmur.
HISTORY OF PRESENT ILLNESS
Diana Scott is a 100-year-old female who presents today for evaluation of a heart murmur.
Ms. Scott has been recently diagnosed with a “new, worrisome” heart murmur. She denies chest pain, syncope, palpitations, fevers, or chills. She reports shortness of breath if she walks too fast, too long, or tries to drink a whole glass of water without stopping. The patient requires a walker and can walk around her cul-de-sac or to the end of the driveway without shortness of breath. Compared to 6 months ago, her functioning has declined 20-30%. Prior to 6 months, symptoms were absent. For the past month she has been experiencing severe, bilateral leg pain, which was limiting her mobility. She did see her doctor last week who completed a chest x-ray and prescribed pain medicine. Occasionally, she feels dizzy but takes medication for this and it subsides. Her ankles have been swelling for the past 6 months, but the swelling fluctuates day to day. Her weight has been slowly decreasing over the past year, with her current weight at 120 pounds, previous weight was 130 pounds. She also reports feeling “overly tired” but attributes this to her polypharmacy.
The patient is unsure if she has completed any cardiovascular testing.
PAST HISTORY
Medical
Hyperlipidemia.
Hypertension.
Hypothyroid.
SOCIAL HISTORY
Requires a walker to ambulate.
FAMILY HISTORY
Son had a myocardial infarction.
Brother had a stroke and has diabetes.
Older sister has an unknown heart problem.
Family is positive for heart disease.
CURRENT MEDICATIONS
Levothyroxine.
Lisinopril.
Simvastatin 20 mg.
Meclizine.
Amlodipine.
ALLERGIES
No known drug allergies.
PHYSICAL EXAM
Constitutional
Elderly, no acute distress.
Cardiovascular
Normal S1, S2 preserved, irregular rhythm and normal rate. 4/6 systolic murmur at the RUSB with mild radiation to the carotids.
Musculoskeletal
Lower extremity edema
Neurologic
Gait normal for age.
RESULTS
EKG
Impression: Sinus rhythm with frequent PVCs as well as anterior septal infarct pattern.
ASSESSMENT
• Cardiac murmur.
• PVCs.
• Hypertension.
• Hyperlipidemia.
• Hypothyroid.
• Lightheadedness/dizziness.
PLAN
Cardiac murmur
Diana has a 4/6 systolic murmur at the RUSB with mild radiation to the carotids. This is most likely representative of aortic stenosis. She does have symptoms including a significant increase in fatigue over the last 6 months, shortness of breath, and some lightheadedness. This could be due to severe aortic stenosis, however, her S2 is relatively preserved which would be more consistent with moderate. She is unsure if she has had an echocardiogram, although some of her outside records do note diastolic dysfunction, so it is possible that she had one as some point in the past. We will order a repeat echocardiogram today to assess overall cardiac structure and function as well as valvular disease. If she does truly have severe aortic stenosis, I briefly discussed a TAVR procedure today as she is not a candidate for a surgical AVR given her age co-morbidities and frailty. She is unsure if she would be interested in this, but we will assess first with the echocardiogram and then discuss further at follow-up. She does not appear significantly volume overloaded today.
PVCs
Her referral mentions tachycardia. Her EKG today shows sinus rhythm with frequent PVCs as well as anterior septal infarct pattern. She does not have any significant palpitations. We will check an echocardiogram to assess overall cardiac structure and function. Depending on results as well as the severity of her aortic stenosis, we will need to consider an ischemic evaluation or possibly a heart monitor to assess the overall burden of PVCs. At this point, she is asymptomatic, so we will start with the echocardiogram only.
Hypertension
She is taking amlodipine and lisinopril. We will continue these as is.
Hyperlipidemia
This is managed by her PCP. She is on simvastatin 20 mg. She is having bilateral leg pain over the past month. This could be related to the simvastatin possibly and given her age, it would not be unreasonable to stop the simvastatin, but I will defer to her PCP. She has no known CAD but if we were to do a TAVR evaluation and this was discovered, a statin would be indicated.
Hypothyroidism
She takes levothyroxine for supplementation and will continue this as is.
Lightheadedness/dizziness
She is on meclizine for this. It is possible that some of her lightheadedness and dizziness are related to the aortic stenosis, and we will do an echocardiogram as noted above. She is also having some PVCs on her EKG, which could be contributing, but she does not feel palpitations. We will consider a monitor but start with the echocardiogram first as noted above.
INSTRUCTIONS
Follow-up in 3 to 4 weeks after her echocardiogram is done to discuss results and next steps.
|
D2N106 | aci | [doctor] hey charles i'm using this cool new recording device to help me with my documentation is that okay with you
[patient] sure
[doctor] awesome how are you doing today
[patient] well i could be better you know i moved out in the city
[doctor] about two years ago bought this big plot of land
[patient] oh
[doctor] i love it lots of deer round awesome
[patient] you be hunter
[doctor] huge hunter i love hunter yeah
[patient] i have a refrigerator full of venison at home
[doctor] do you
[patient] mm-hmm
[doctor] you want to carry share sure yeah we can switch
[patient] nice but so the thing is i have noticed that for some reason my breathing
[doctor] is n't what it used to be
[patient] sure
[doctor] yeah it's you know i i seem to catch my breath a lot more than i used to and i consider myself to be pretty healthy
[patient] you look pretty healthy
[doctor] thanks so do you thank you you you're feeling short of breath
[patient] yes
[doctor] okay is there you know is there any other symptoms that you have with that i get like you know mid shortness of breath suddenly for some reason i'm not quite sure why
[patient] hmmm
[doctor] eyes they're water does n't make very much sense to me
[patient] mm-hmm
[doctor] i always think it's allergies
[patient] okay
[doctor] mostly could be
[patient] i have a dog that eyes water like that she always gets eyebugers
[doctor] yeah i get eyebugers too
[patient] uh
[doctor] crazy uh the last time it happened i went to the urgent care and they gave me a nebulizer that helped
[patient] they prescribed me an inhaler that i use now when i feel the symptoms coming on
[doctor] okay great do you ever notice a rash with any of this
[patient] no
[doctor] do you have any nausea vomiting
[patient] no
[doctor] besides when you go out heavy drinking right
[patient] i mean i diarrhea quite a bit once i go out
[doctor] i understand that
[patient] heavy drinking
[doctor] yeah do you ever get lip or throat swelling
[patient] no
[doctor] have you ever had any issues with allergies in the past
[patient] no
[doctor] hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house
[patient] i have noticed them in all three situations
[doctor] hmmm
[patient] in the house when the cat is n't around and outside as well
[doctor] hmmm yeah i'm not a big cat person
[patient] no neither
[doctor] do you do you have any symptoms now well which is
[patient] no
[doctor] no no travels and no symptoms right now
[patient] mm-hmm
[doctor] okay
[doctor] okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on your body there is no angioedema which is just swelling of your lips like you mentioned no audible stridor which is a bad noise in your airway when it gets swollen so that's good news if you just want to take a deep breath listening to your lungs on your lungs exam i do appreciate some faint expiratory wheezing bilaterally in all lung fields so i know you had a chest x-ray when you came in i'm looking at that chest x-ray right now and your pulmonary function test and they were both normal so let's talk a little bit about what i think is going on for your first problem you have newly diagnosed allergic asthma so i want you to continue the albuterol inhaler i do n't want you to wait until your symptoms flare up or are bad take it as soon as you start to feel any symptoms at all i'm gon na prescribe something else called singulair ten milligrams you might have seen some commercials for it
[patient] hmmm
[doctor] you take that once daily and that's gon na help decrease the occurrences of your asthma
[patient] hmmm
[doctor] i also am gon na proceed with allergy testing have you ever had an allergy test before
[patient] no
[doctor] okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next week to schedule the skin testing do you have any questions for me
[patient] should i come my cats
[doctor] yes | CHIEF COMPLAINT
Shortness of breath.
HISTORY OF PRESENT ILLNESS
Charles Sullivan is a pleasant 45-year-old male who presents to the clinic today for the evaluation of shortness of breath. The onset of his symptoms began 2 years ago. He has noticed that his breathing is not what it used to be. He describes an increased need to catch his breath. The patient also reports he gets “mid-shortness of breath” without reason. He has been seen at an urgent care where he received a nebulizer treatment and was prescribed an inhaler, which he uses when his symptoms are present. The patient states his symptoms are aggravated by living with a cat in his house and are present even when the cat is not around or is outside. He has experienced epiphora with rheum present that he attributes to allergies. He has had diarrhea after consuming large amounts of alcohol. He denies any symptoms at this time including shortness of breath, rash, nausea, vomiting, and lip or throat swelling. The patient denies any previous issues with allergies.
He enjoys hunting.
VITALS
Oxygen Saturation: Normal on room air.
PHYSICAL EXAM
CONSTITUTIONAL: In no apparent distress.
HEAD: No angioedema.
RESPIRATORY: No audible stridor. I do appreciate some faint expiratory wheezing bilaterally in all lung fields.
SKIN: No rash.
RESULTS
A chest x-ray, obtained and reviewed today is normal.
Pulmonary function test, obtained and reviewed today is normal.
ASSESSMENT
Newly diagnosed allergic asthma.
PLAN
After reviewing the patient's examination, radiographic findings, and pulmonary function test results today, I have had a lengthy discussion with him regarding his current symptoms. He will continue to use the albuterol inhaler; however, he should limit its use to when he is experiencing a severe flare-up of symptoms. I advised he should take it as soon as he starts to feel any symptoms at all. I have also prescribed the patient Singulair 10 mg to be taken once daily. This should help to decrease the occurrences of his asthma. I have also recommended we proceed with an allergy skin test to target what his triggers are in the hope that we can avoid any other management. If we unable to determine his allergens, then we may consider further testing or immunotherapy.
INSTRUCTIONS
The patient will follow up with me in 1 week for skin testing. |
D2N107 | aci | [doctor] so bryan it's nice to see you again in the office today what's going on
[patient] i was in my yard yesterday and i was raking leaves and i felt fine and then when i got into my house about two hours later my back started tightening up and i started getting pins and needles in my right foot
[doctor] alright have you ever had this type of back pain before
[patient] i had it once about three years ago but it went away after a day
[doctor] okay and did you try anything for the pain yet did you take anything or have you have you tried icing
[patient] put some ice on it and i tried two advils and it did n't help
[doctor] okay does it get better when you're laying down sitting standing
[patient] yeah i think the only thing that helped was a hot shower and it feels a little better when i sit
[doctor] okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately
[patient] i i i normally do n't do any physical activity
[doctor] yeah i hear you i make a i make my husband do all the yard work too so alright let me take a look at that low back if if you bend over does that hurt
[patient] it hurts a little bit when i bend over yes
[doctor] okay how about when you stand back up
[patient] no pain
[doctor] okay so no pain on extension some pain on flexion how about when i push right here on your back
[patient] yeah that hurts
[doctor] okay so some pain to palpation right around the l5 can i have that
[patient] what happens when family members chime in like i'm doing right now because i actually think it was it hurts more when he stands up because i've watched him bend over but it's when he stands up that it really hurts
[doctor] okay and and what's your relationship
[patient] partners
[doctor] okay so your partner is here with you today and reports that he is also having pain when you are standing up
[patient] i've spent so many times you know who i am
[doctor] so that's right you always come in together have you noticed anything else partner when when he is
[patient] i'm worried about it because he is you know his pain tolerance is so high and he would n't be saying anything if it really was n't a problem because it's not at all like last week when he thought about raking leaves but did n't actually rake leaves but then his back did n't hurt as much but this time it really hurts
[doctor] okay so you think this is more of a long term injury
[patient] no he was just thinking about it hurting when he thought about raking but it did n't
[doctor] okay alright and have you noticed any any prior pain with with the back
[patient] i do n't want to take this away you better go back to talking to him
[doctor] that's alright let's see how it turns out okay so how about if you if i push down on both your feet like this can you push back up on my hands
[patient] can you repeat that
[doctor] if i'm pushing down on your feet can you push push your feet back
[patient] i
[doctor] alright so your dorsiflexion is normal looks like pulses are equal in all extremities you said you had a little bit of a tingling sensation in which leg
[patient] that would be my right leg
[doctor] okay so some tingling in your right leg alright so i know that you had an x-ray when you came in because we always do x-rays when we have our patients come in of your low back and everything looks normal from that perspective so for your back pain sounds like you probably sprained your low back so i what i want you to do is let's rest it i'm going to prescribe some meloxicam have you taken that before
[patient] i have not taken meloxicam
[doctor] alright so i'll prescribe that i'm also gon na prescribe some physical therapy i know you said you have n't been overly active and your partner reported the same thing for a long time so we might wan na get you into some pt and hopefully get you back back in shape get you some stretches that you can do and some exercises and then you know if it's not improving i want you to send me a message and we can possibly look into see if there is anything else going on potentially an mri if it's still not improving does that sound like an okay plan
[patient] it sounds reasonable
[doctor] alright
[patient] i think he should have an mri now i think he had surgery yesterday i think he should have an mri now this it's been hurting for like six hours now and she had an mri we are really worried about it
[doctor] alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving
[patient] good answer
[doctor] alright alright hope you feel better | CHIEF COMPLAINT
Low back pain.
HISTORY OF PRESENT ILLNESS
Bryan Brooks is a pleasant 39-year-old male who presents to the clinic today for the evaluation of low back pain. He is accompanied today by his partner.
Approximately 2 hours after he finished raking leaves yesterday, the patient began to feel a tightening sensation in his low back and tingling in his right foot. Prior to this, he recalls a similar episode approximately 3 years ago in which his symptoms resolved after 1 day. Ice and Advil provided no relief, but his pain is less severe when he is in a seated position and taking a hot shower helped alleviate his pain. The patient's partner reports that his pain seems to worsen when he stands up.
REVIEW OF SYSTEMS
Musculoskeletal: Reports low back pain.
Neurological: Reports tingling in the right foot.
PHYSICAL EXAM
NEURO: Normal strength and sensation.
MSK: Examination of the lumbar spine: No pain on extension. Some pain with flexion. Pain with palpation around L5. Dorsiflexion is normal. Pulses are equal in all extremities.
RESULTS
X-rays obtained and reviewed in office today were normal.
ASSESSMENT
Low back sprain.
PLAN
The examination findings and x-ray results were discussed with the patient and his partner today. I recommend we treat this conservatively with rest, meloxicam, and formal physical therapy. If he fails to improve, we can consider obtaining an MRI for further evaluation.
INSTRUCTIONS
The patient will follow up in 2 weeks. |
D2N108 | aci | [doctor] hey gregory good to see you today so take a look at my notes and i see that you're here you've had a nonhealing foot ulcer so can you tell me how you're doing how long have you had it what's going on with it
[patient] sure so i've had it for about two months now and it's recently become red and is draining so i was concerned about how it's healed
[doctor] okay and when you when you got it would you have any trauma to your foot or it just just did it pop up all of a sudden
[patient] i think i may have gotten it from walking barefoot on the beach
[doctor] okay alright and i saw you you did see your pcp before you came in did they put you on antibiotics
[patient] they did start me on some medication but i did n't i did n't pick them up from the pharmacy yet
[doctor] okay do you know which ones that they prescribed for you
[patient] i do n't recall the name exactly
[doctor] do n't recall alright
[patient] something i had taken it before
[doctor] okay so when you what beach did you go to when you you hurt it
[patient] i'm sorry
[doctor] so i was asking which beach did you did you go to when you hurt your foot
[patient] at i was at dewey beach in my ambulance
[doctor] dewey beach wow that sounds like fun i wish i could be a mab right now but all or as lucky as i guess as you are to go to dewey beach okay so does it hurt
[patient] it sometimes it throbs does n't i do n't have specific pain but sometimes it does feel like there is some throbbing going on and again my my biggest concern is the it started to drain and it looks a little red
[doctor] okay
[patient] i have n't had that before
[doctor] okay and that makes sense alright so as far as your diabetes you know and i think that's probably a a major cause of this not being able to heal how well are how well is that controlled
[patient] i take my medication but i do n't check my sugar all the time
[doctor] okay do you
[patient] i'm not really sure how
[doctor] okay do you know what your last a1c is i'm pretty sure you doc talk to you about it
[patient] i think they told me it was around ten
[doctor] around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look normal you do n't have a fever so let me just take a look at your foot so on your foot exam there is a one by two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint there is some redness some drainage present you have some edema around it there is fluid like you said that's coming out of it i do n't see any necrosis you do n't have any odor and i do n't appreciate any bony exposure so it pretty much is like you said it's it's red it's swollen i think you have an infection in there as well so when i touch it does that hurt
[patient] no i i feel like increased pressure but it's not distinct
[doctor] okay alright that's good so before you came in we did get an x-ray of your right foot and there is no evidence of osteomyelitis that means that luckily you do n't have a bone infection so that's great i think it's just in your skin so let's talk a little bit about your assessment and plan so you do have that diabetic foot ulcer and what i wan na do is i wan na order an abi ankle brachial index just to determine the blood supply in your foot to see if we can actually heal that ulcer i'm gon na also perform a debridement here just to take off some of that dead tissue and then i'm gon na prescribe you some clindamycin you can do that four hundred milligrams you take that for seven days take that twice a day just to try to get rid of that infection which you currently do have and that will get rid of some of that that redness and and drainage that that's happening right now did your doc did your pcp give you a surgical shoe something that you would wear while this is happening
[patient] they did n't they mentioned that you may be able to give it to me
[doctor] okay yeah we could definitely get you a a shoe because if you wear your regular shoes that pressure on that foot can really irritate it and take you backwards so i'll get you a shoe where you can wear that for the next month you know we just wan na make sure that it does heal and then i wan na see you back again in two weeks and we can we'll possibly do another debridement at that time we'll just take a look and see how the tissue is doing so how does that sound
[patient] that sounds great
[doctor] alright do you have any other question
[patient] i do if anything happens in between
[doctor] please feel free to call the office yeah please feel free to call you call the office we can definitely get you in you know if you are having any other issues and if it's an emergency if you feel like you're getting a fever feeling well please go to the urgent care or the er if you feel getting black or anything like that but otherwise we'll see you back in two weeks
[patient] okay sounds great thanks document
[doctor] alright great | CHIEF COMPLAINT
Right foot ulcer.
HISTORY OF PRESENT ILLNESS
Gregory Hernandez is a pleasant 40-year-old male who presents to the clinic today for the evaluation of a non-healing right foot ulcer. Onset of ulcer was approximately 2 months ago after walking barefoot on the beach. He reports the ulcer has recently become red and is draining. At times he will also experience throbbing pain. He has seen his primary care physician and was prescribed antibiotics, however, he has not started them yet and does not recall the name of the medication.
The patient is a diabetic. He is taking medication for this, however, he does not monitor his blood sugar consistently. His last A1C was around 10.
MEDICAL HISTORY
Patient reports history of diabetes.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right foot pain.
Skin: Reports right foot ulcer with redness and drainage.
VITALS
Vital signs are normal.
PHYSICAL EXAM
MSK: Examination of the right foot: There is a 1 x 2 inch circular wound on the dorsal aspect laterally just proximal to the 5th MTP joint. There is some redness and drainage present as well as edema. No necrosis, odor, or bony exposure. Nontender to palpation.
RESULTS
3 views of the right foot were taken. These reveal no evidence of osteomyelitis.
ASSESSMENT
Right diabetic foot ulcer.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. I have recommended that we obtain an ankle brachial index to determine the blood supply in his foot. Debridement will be performed. A prescription for clindamycin 400 mg 2 times per day for 7 days will be provided as he does seem to have an infection. He will also be placed in a surgical shoe to provide increased support for the next month.
INSTRUCTIONS
The patient will follow up with me in 2 weeks to assess his progress and for possible repeat debridement. He has been advised to call the office if his symptoms worsen and we will get him in sooner, however, if he starts to develop a fever or necrosis he has been instructed to go to the ER.
|
D2N109 | aci | [doctor] so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle
[patient] well we had a long spring and the other day we got some snow and ice i was walking to my car and i slipped and my left ankle kinda turned underneath me
[doctor] okay and so this happened couple days ago or how many days ago
[patient] two days ago
[doctor] two days ago okay and so it's your left ankle and it kinda just twisted underneath you on the kind of on the inside
[patient] yeah more on the it's more on the outside of my hips
[doctor] and did you fall down or did you just kind of cut catch yourself
[patient] no i fell
[doctor] okay and were you able to get up afterwards or somebody helped you up
[patient] i was but it was very sore and then started swelling and quite a bit of pain so it's hard to walk
[doctor] sure have you tried anything for pain or the swelling or anything like that
[patient] ibuprofen some ice and elevation
[doctor] okay has that helped much or not really
[patient] a little bit
[doctor] okay and any pain above your ankle does it hurt on your on your calf or your lower leg at all or knee at all
[patient] no it's mostly just the outside of my ankle
[doctor] okay got it and no bleeding or i'm sure it's a little swollen probably
[patient] yeah it's swollen but no bleeding
[doctor] well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood sugars been how how're you managing that any issues with that
[patient] no they've been pretty stable
[doctor] okay
[patient] so with my diet
[doctor] good
[patient] so
[doctor] you're checking your sugars regularly as well
[patient] yes
[doctor] okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you seen the ophthalmologist recently for your eye exam for your diabetes checkup or no
[patient] i am due for one of those in the next couple of weeks
[doctor] okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that
[patient] i have an appointment
[doctor] perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything
[patient] i need a refill on that yes
[doctor] okay alright well let me examine you here for a second so i'm gon na go ahead and do my match exam and i'm just gon na verbalize some of my findings so i can put that into my record okay so your neck exam is fine there is no bruits your lungs are clear your heart exam is normal you do have a two over six systolic ejection murmur you had that in the past unchanged from before so that's not really worried about that your belly exam is good on your ankle exam on your left ankle you do have some tenderness over the lateral malleolus and you do also have some tenderness over this bone here which is the fifth metatarsal so i do n't see any there is some swelling there some redness but there is some pain with valgus stressing of your ankle as well and let me turn off my phone here and also you do have otherwise normal sensation normal pulses so on your so my diagnosis for your ankle is i think you probably have an ankle sprain but i would like to order an x-ray of your ankle because you do have some tenderness over this bone and i'm sometimes worried about a fracture so i'm gon na go ahead and get an x-ray i'm gon na put you in a splint we're gon na put you in a in an air splint and i'll give you some crutches until i get the x-ray back i want you to do just avoid weightbearing just to make sure there is no fracture there i will give you some naprosyn five hundred milligrams twice a day for pain control keep it elevated put some ice on it i think those are all good things and if the x-ray shows a fracture i'm gon na go ahead and give you a call back and we'll send you to orthopedics but right now let's try this air splint if there is no fracture i will probably have you take off the air splint and do some partial weightbearing and see how it goes does that sound like a reasonable plan for you
[patient] that's a great plan i need to get back to exercising so
[doctor] okay
[patient] thank you
[doctor] perfect and for the diabetes keep the eye appointment that you already have you know continue with the metformin i'm gon na order another hemoglobin a1c today we'll check some baseline labs as well since it's been a while since we checked them and then once if you have any issues or you know give me a call we can get you into the office and for the high blood pressure i'll go ahead and refill the norvasc today you're doing a great job with that it sounds like continue to monitor that if something changes certainly call me we can get you in sooner okay
[patient] thank you
[doctor] sounds good sounds good good great seeing you thanks stephanie
[patient] thank you | CHIEF COMPLAINT
Left ankle pain.
MEDICAL HISTORY
Patient reports history significant for type 2 diabetes and hypertension.
MEDICATIONS
Patient reports taking metformin and Norvasc.
REVIEW OF SYSTEMS
Musculoskeletal: Reports left ankle pain and swelling.\ Denies left calf pain, lower left leg pain, or left knee pain.
VITALS
Blood pressure: 120/70 mmHg
PHYSICAL EXAM
Neurological
- Examination: Sensation intact in left lower extremity.
Neck
- General Examination: No bruits.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Examination: Pulses are normal in left lower extremity.
- Auscultation of Heart: 2/6 systolic ejection murmur, unchanged from previous exam.
Musculoskeletal
- Examination of the left ankle: Tender to palpation over the lateral malleolus and fifth metatarsal. Trace edema. Mild erythema. Pain with valgus stress testing.
RESULTS
Hemoglobin A1c: 6.8
ASSESSMENT AND PLAN
1. Left ankle pain.
- Medical Reasoning: Given the nature of her injury, I believe this is an ankle sprain.
- Patient Education and Counseling: I advised the patient that I will contact her with the results of her x-ray, and that if these reveal a fracture, we will put in a referral to orthopedics for further evaluation.
- Medical Treatment: X-ray ordered to rule out fracture. We will place her in an air splint and have her ambulate with crutches to avoid weightbearing until we get the x-ray results. She will start Naprosyn 500 mg twice daily for pain control. Continue with ice and elevation.
2. Diabetes type 2.
- Medical Reasoning: This appears to be well controlled with her current regimen.
- Patient Education and Counseling: I encouraged her to keep her appointment with ophthalmology for her diabetic eye exam.
- Medical Treatment: We will keep her on her current dose of metformin and order a repeat hemoglobin A1c. We will also obtain a set of baseline labs.
3. Hypertension.
- Medical Reasoning: She is doing well with Norvasc.
- Patient Education and Counseling: I encouraged her to continue with home monitoring and knows to contact the office if needed.
- Medical Treatment: We will keep her on her current dose of Norvasc. A refill was sent for this today.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N110 | aci | [doctor] okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right
[patient] yes
[doctor] so can you tell me about that how are you doing
[patient] well i've been doing okay but i've had this wound on my right foot for a couple of weeks and it's not getting better i saw my pcp and they referred me to you i i used to see a podiatrist and a couple of years ago but they moved and i was n't able to get another one
[doctor] okay and how long have you had the wound
[patient] about two to three weeks
[doctor] okay have you had any kind of trauma to that foot
[patient] no i bought a new pair of shoes to travel with and the neuropathy i guess i did n't feel that they were too tight at first it was just a blister but it looked a lot worse now i've been putting a band-aid on it and
[doctor] okay and so did your doctor put you on any antibiotics when they they saw your foot
[patient] yes i finished the course yesterday the wound looked about the same though
[doctor] okay now does it hurt
[patient] no i ca n't feel it
[doctor] okay now have you had any other symptoms like fever chills drainage from the wound or anything along those lines
[patient] no but when i take my sock off sometimes it sticks to the wound even when i put a band-aid on
[doctor] okay well are you still wearing those same shoes that cause the problem
[patient] no i'm upset
[doctor] i'm so upset too i love those shoes
[patient] no i'm so upset i i love those shoes
[doctor] okay so what kind of shoes are they
[patient] they're hoka's
[doctor] ah so where did you get them
[patient] i got them at rei couple of years ago
[doctor] they're pretty good about helping you to fit your fit you in a shoe are n't they
[patient] yeah
[doctor] so what do you like about them
[patient] they are comfortable they are easy to take on and off and they provide good stability
[doctor] that's good so you've had some issues with stability sometimes or
[patient] yes
[doctor] okay okay well another question i want to ask you is how is your diabetes doing
[patient] i do n't think it's too bad my last hgb a1c was a little over eight
[doctor] okay alright well let me just do a quick physical exam okay for vital signs your temperature is ninety eight . one your vital signs look good your heart rate is seventy two respirations sixteen blood pressure is one ten over sixty five okay so on your foot exam let's see there is a one by two inch circular wound on the dorsal aspect of the lateral right foot it is just proximal to the right fifth to the fifth mtp joint and there is some yellow slough present with minimal granulation tissue there's no surrounding erythema or cellulitis and there's no evidence of fluid collection there's no necrosis there is no odor i do not appreciate any bony exposure on on vascular exam there are palpable bilateral femoral and popliteal pulses there are no palpable dp or pt pulses but doppler signs are present okay so does this hurt when i touch it here
[patient] no it's okay
[doctor] okay alright so i've reviewed the results your right foot x-ray that we did before you i came in the room and this shows no evidence of osteomyelitis which means there is no evidence of bone infection so that's really good so let me tell you a little about my assessment and plan for you so for your first problem your diabetic foot ulcer so i want to order an ankle brachial index abi to determine the blood supply to your foot to see if you can heal this wound i'm also gon na perform a debridement here in the office to take off some of the dead tissue and then next i'm going to prescribe a collagenase ointment to be applied to the wound once daily and then cover with a dry sterile dressing now we will continue this until we see the wound shrinking and a nice pink tissue is present and i want you to wear a surgical shoe to take pressure off of the area okay so i do n't think any more antibiotics are needed at this time and i want to see you again in two weeks so we may need to refer you to a vascular specialist if the abi indicates your blood supply is not optimal for wound healing okay
[patient] okay
[doctor] okay so for your diabetes it's gon na be very important to get your diabetes under control in order to get the wound to heal so we might even go ahead and get a diabetic consult so that we can go over some some maybe some ways you can modify your diet without a being too much but maybe that can bring down your hemoglobin a1c into a little bit better level okay
[patient] okay
[doctor] alright do you have any other questions
[patient] no
[doctor] okay | HISTORY OF PRESENT ILLNESS
Wayne Jenkins is a pleasant 43-year-old male who presents to the clinic today for the evaluation of a right foot wound, onset 2 to 3 weeks ago. He was seen by his primary care physician who referred him to our office. His last visit with a podiatrist was 2 years ago, however they moved, and he has been unable to get another podiatrist. He denies any specific injury.
The patient purchased a new pair of shoes and was breaking them in prior to traveling. Initially, he did not feel that the shoes were too tight, however a blister formed on his right foot. The patient does have neuropathy and notes this might be why he did not notice the tightness. His blister soon became a wound and he was seen by his PCP. He was placed on a round of antibiotics, which he completed yesterday. He denies any changes to the appearance of the wound. The patient denies pain or drainage. His sock will occasionally stick to his wound, regardless of if he has a Band-Aid covering it. The patient has discontinued the use of these shoes. Occasionally, he has issues with stability, which was a primary purpose of purchasing these shoes. He denies any fever or chills.
Regarding his diabetes, his last hemoglobin A1C was 8.
REVIEW OF SYSTEMS
Constitutional: Denies fever and chills.
Skin: Reports right foot wound.
Neurological: Reports neuropathy.
VITALS
Temperature: 98.1.
Heart rate: 72.
Respiration: 16.
Blood pressure: 110/65 mm Hg.
PHYSICAL EXAM
CV: Palpable bilateral femoral and popliteal pulses. No palpable DP or PT pulses but Doppler signs are present. No evidence of fluid collection.
SKIN: On the right foot, there is a 1 x 2 inch circular wound on the dorsal aspect of the lateral right foot that is just proximal to the 5th MTP joint. There is some yellow slough present with minimal granulation tissue. No surrounding erythema or cellulitis. No necrosis. No odor.
RESULTS
3 views of the right foot were taken today. These reveal no evidence of osteomyelitis.
ASSESSMENT
1. Right foot diabetic ulcer.
2. Diabetes.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. At this time, I have recommended that we obtain an ankle brachial index ABI to determine the blood supply to his foot to see if he can heal this wound. I have also performed a debridement in the office to remove some of the dead tissue. I have prescribed a collagenase ointment to be applied to the wound 1 time daily and instructed him to cover with a dry sterile dressing. He will continue this until we see the wound shrinking and the nice pink tissue is present. I have also recommended that the patient be placed in a surgical shoe to take pressure off the area. I do not think that antibiotics are needed at this time. He may need to see a vascular specialist if the ABI indicates that his blood supply is not optimal for wound healing.
Regarding his diabetes, I explained the need for controlling his diabetes and the effects this will have on wound healing. I have recommended a diabetic consultation to discuss diet modifications to bring his hemoglobin A1c to a better level.
INSTRUCTIONS
The patient will follow up with me in 2 weeks to check on his progress. |
D2N111 | aci | [doctor] hey william so i see that you injured your knee could you tell me a bit about what happened
[patient] yeah i thought it was a good idea to go to the trampoline park with my wife and heard a snap and instant pain when i was on the trampoline
[doctor] okay alright and so do do you go to the trampoline park often
[patient] i do n't and i think that's the issue
[doctor] okay so this is the first time you'd ever done something like that
[patient] yes
[doctor] okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class
[patient] no it's just for fun
[doctor] okay and do you have like a regular exercise regimen at all
[patient] try to not consistent with it
[doctor] okay no that's fine this is not a place of judgment i just i'm just trying to understand like if a little bit more of the background okay so we went to the trampoline park which knee where did you hurt
[patient] my right
[doctor] okay your right knee and so based on like your inside and outside which part hurts more
[patient] it's kind of the outside of the knee
[doctor] alright so the lateral aspect not a problem and you said that you heard a pop when you landed right
[patient] yeah
[doctor] okay have you taken anything for the pain
[patient] just tylenol
[doctor] alright so did the tylenol help
[patient] not really
[doctor] okay alright and so hmmm when does it have you tried anything else like did you ice it use heat anything like that
[patient] no i just kinda elevated it and that was about it
[doctor] okay that's fine and how long ago did this happen
[patient] a week ago
[doctor] okay alright so you put up with the pain for a week that's i'm proud of you for that
[patient] i do n't like to come to the doctors
[doctor] excuse me i feel rejected right now why why would you say something like that it's fine but you know i i like it when you're not here either because that means that you're doing a good job so let's see about like getting your knee fixed up but i want to talk about some of the other issues that you have first so we know that you have hypertension right and i discussed maybe you getting a blood pressure cuff because i needed you to measure those a bit more regularly did you get the cuff
[patient] what no
[doctor] no okay that's fine have you measured your blood pressure recently at all
[patient] no
[doctor] okay are you still taking your medication because i see you're on twenty milligrams of lisinopril
[patient] yeah most days i remember
[doctor] okay
[patient] ra i'm not suspicious but we're just gon na go with that okay because looking at your vitals it it is of still a bit high i'm not really comfortable i see like a hundred and eighty over you know eighty and
[doctor] that's not where we wan na be so i wonder if we might need to adjust your medication but let's talk about your diabetes how are your blood sugars
[patient] i think they're little bit better
[doctor] okay what makes you think that have you been taking them
[patient] yeah i check it you know most days again kinda when i remember
[doctor] okay how often are you checking it
[patient] i would say four five times a week
[doctor] okay you might wan na switch to maybe two or three times a day but you know that's something i'm glad that you are measuring are you taking your metformin
[patient] yes
[doctor] okay and then i think we have you on five hundred milligrams correct
[patient] yes
[doctor] alright how is your diet
[patient] kinda the same as my exercise decent could be better
[doctor] alright and okay not a problem so what is your do you are you measuring your calories at all looking at your macros are you just eating what you feel like
[patient] yeah just trying to watch what i eat more than anything but nothing specific
[doctor] okay and are you do you know if you're particularly focused on your salt like is it like a low salt diet
[patient] no just trying to watch my carbs a little bit more but not counting or anything
[doctor] alright so like is it a specific diet i just wan na make sure like are you on like the keto diet
[patient] no
[doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally i would like to look at your knee though so when i press here on the outside does it hurt
[patient] little bit
[doctor] okay and then when i press on the inside does it hurt
[patient] no
[doctor] alright can you bend your knee and straighten it
[patient] i can i think that's all i can i can bend
[doctor] mm-hmm alright so are you having problems walking can you bear weight
[patient] i can but i have a little bit of a limp
[doctor] okay so do you mind getting up and walking for me really quickly alright so i do notice that there is a slight gait like there is a small sorry you are correcting you do have a limp i i am a little worried about that but it's probably it's probably the superficial when i'm looking at your knee i do notice some like ecchymosis and edema that just means bruising and swelling along the lateral aspect of your knee i do n't notice any effusion and it looks like you have a decent range of motion but i do understand that you know you are experiencing pain with some movement okay i'm gon na go ahead and order an x-ray and when you come back we can have that discussion alright so i reviewed the results of your right knee x-ray which showed no evidence of fracture or bony abnormality so let's talk about my assessment and plan alright so for your first problem of right knee pain i think you have a lateral a lateral ligament strain i wan na prescribe some meloxicam which is gon na be fifteen milligrams daily for pain and swelling i'm gon na refer you to physical therapy to help strengthen the muscles around the area and to prevent further injury if you're still having pain we can do further imaging imaging but like this is a common injury that tends to heal on its own for your second problem with hypertension i wan na continue the lisinopril at twenty milligrams and order an echo i am concerned that we might not be getting your blood pressure to where we need it to be so we might have to do some medication modification for your third problem with diabetes i wan na order an a1c i know that you said you have been measuring your blood sugars but i think this would give us a better image of what's been happening long term and i also wan na order a lipid panel in case we need to make any adjustments to that medication as well do you have any questions
[patient] sounds good
[doctor] alright awesome | CHIEF COMPLAINT
Right knee injury.
HISTORY OF PRESENT ILLNESS
William Russell is a pleasant 57-year-old male who presents to the clinic today for the evaluation of a right knee injury. He has a past medical history significant for hypertension and type 2 diabetes.
Approximately 1 week ago, the patient sustained an injury to his right knee while at a trampoline park. He explains that he was jumping on a trampoline when he heard a snap, followed by instant pain in the lateral aspect of his knee. This is not a common activity for him, and he admits that he is inconsistent with exercise. As far as treatment, he has been elevating his knee and taking Tylenol without significant relief of his pain. He has not tried applying heat or ice to the area.
In terms of his hypertension, the patient admits that he did not purchase a blood pressure cuff as previously recommended. While he does not monitor his blood pressures at home, he has been compliant with lisinopril 20 mg.
His diabetes appears to be stable based on home monitoring, although he is only checking his blood glucose levels 4 to 5 times per week. He does not follow any specific diet plan, but he does try to make healthier choices such as limiting his carbohydrate intake. He has also been taking his metformin 500 mg as prescribed.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right knee pain.
VITALS
Blood pressure: 180/80 mmHg
PHYSICAL EXAM
CV: Regular rate and rhythm. No murmurs.
RESPIRATORY:
Lungs are clear bilaterally.
MSK: Examination of the right knee: Mild tenderness to palpation at the lateral aspect. Ecchymosis and edema along the lateral aspect. No effusion. Decent range of motion. Pain with movement.
RESULTS
X-rays of the right knee were obtained and reviewed. These reveal no evidence of fracture or bony abnormality.
ASSESSMENT
1. Right knee pain, lateral ligament strain.
2. Hypertension.
3. Diabetes type 2.
PLAN
After reviewing the patient's examination and radiographic findings today, his symptoms appear to be consistent with a lateral ligament strain of the right knee. I am going to prescribe meloxicam 15 mg once daily for pain and swelling. I also put in a referral for physical therapy so he can work on strengthening the muscles around the area and prevent any further injury. We can consider further imaging if he continues to have pain, but I explained that this is a common injury that typically heals on it's own.
For his hypertension, I'm concerned that his blood pressure is not well controlled at this time, so we may need to modify his medication. I'm going to order an echocardiogram for further evaluation, but I want him to continue taking his lisinopril 20 mg for now.
For his diabetes, he stated that he has been measuring his blood glucose levels 4 to 5 times per week, but I want him to start measuring them 2 to 3 times per day. His hemoglobin A1c levels should provide more detail as far as his long-term progress so we will order that today. I'm also going to order a lipid panel and we can determine if any adjustments need to be made to his medication. In the meantime, he should continue taking metformin 500 mg.
|
D2N112 | aci | [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 | HISTORY OF PRESENT ILLNESS
Matthew Hill is a pleasant 44-year-old male who presents to the clinic today for the evaluation of back pain. The patient was referred from his primary care physician. The onset of his pain began 30 years ago, when he fell off of a roof. He endorses that it was very bothersome and he was unable to play football. He states that he was told that he may have a fracture at that time. The patient reports that his pain has worsened 1 month ago. He locates his pain to his lower back, which radiates into his left hip, down his left leg, on the side of his calf, and into his left big toe. The patient describes his pain as an "electrical tooth ache" that radiates down his entire left leg. He notes that he has to use a cane to walk as his left foot drags when he walks. He rates his pain level as a 6 to 8 out of 10, however it can get to a 13 out of 10 at its worst. He states that he did not take any medication before his appointment so it did not affect his pain during our visit. The patient notes that he was in the waiting room for 30 minutes today and states that it made his symptoms worse. His pain is aggravated by standing, ambulating, coughing, and sneezing. The patient states that he is unable to tie his shoes secondary to the pain. The patient states that his pain is alleviated by lying down. He also reports weakness in his bilateral legs and his back. The patient denies any numbness or tingling. The patient has attempted NSAIDs in the past without relief. He has also attended physical therapy.
PHYSICAL EXAM
CONSTITUTIONAL: Vitals look good.
MSK: Examination of the lumbar spine: No bony abnormalities. No redness. No bruising present. Pain with palpation at the L4 vertebrae. Positive for pain with flexion and extension of the back. 4/5 strength on the left, 5/5 strength on the right. Reflexes are brisk. Motor and sensory are intact throughout the bilateral lower extremities.
RESULTS
The MRI of the lumbar spine was reviewed today. It revealed a disc herniation at the level of the L4-5 vertebrae. It is associated with some nerve root impingement.
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. |
D2N113 | aci | [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 | CHIEF COMPLAINT
Hepatitis C.
SOCIAL HISTORY
Patient reports personal history of intravenous drug use over 15 years ago. She is currently smoking 1-2 cigarettes per day, previously 1 to 1.5 packs per day. She also has a history of heavy alcohol use, but now drinks approximately 1 beer per day, more on the weekends.
FAMILY HISTORY
Patient reports family history significant for hypertension, diabetes, and depression.
REVIEW OF SYSTEMS
Constitutional: Reports fatigue.
All other systems were reviewed and are negative.
VITALS
Vitals look good today.
PHYSICAL EXAM
Constitutional
- General Appearance: in no apparent distress.
Respiratory
- Auscultation of Lungs: No wheezes, rales, or rhonchi.
Cardiovascular
- Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur, unchanged.
Gastrointestinal
- Examination of Abdomen: No masses or tenderness. No hepatosplenomegaly.
- Auscultation: Bowel sounds normal.
Musculoskeletal
- Examination: No edema.
Integumentary
- Examination: No signs of jaundice.
RESULTS
HCV antibody: Positive
AST: 39
ALT: Within normal limits
Albumin: Within normal limits
Bilirubin, total: Within normal limits
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.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up in 3 weeks.
|
D2N114 | aci | [doctor] alright
[patient] good morning Julie how are you doing today
[doctor] i'm doing okay i'm just a little nervous about what's been going on with my headaches
[patient] okay so i know you were sent here by your your pcp what was your understanding of why you were sent here
[doctor] yeah so i actually have been someone who been struggling with headaches for years now ever since i was a teenager and they used to be around my when i would have my menstrual my menses but as i got older i noticed that it has been with that and also i can get it when i'm really stressed but recently and why i went to her is because my headaches have been getting a lot more they've just been happening a lot more frequently and a lot more severe
[patient] okay can you tell me a little bit about them what how do they how do they feel when they come on
[doctor] so they say mostly on my right side and it even seems like it's like behind my eye and it just like this pulsing like this really bad pulsing sensation
[patient] okay do you notice these any activities or time of the day that makes them worse i know you said they they seem to get worse around your menstrual periods but is there any time of the day or that makes them worse
[doctor] i i have noticed that you know i've been trying to exercise more in order to lose weight but i ca n't even really exercise for very long because i start of as soon as i start to jog i my headaches the headaches come back on a lot worse so i notice it when i'm exercising
[patient] okay and do you seem to have any other symptoms when you get these headaches i've been having a ringing in my ears for a few months now and then what really scared me is that now i'm starting to get some blurred vision it's not all the time but it it will come and go but some blurred like on the
[doctor] in my on the side of my vision
[patient] okay okay and have you experienced any numbness or tingling to your hands or feet or your face
[doctor] no i have n't
[patient] okay so you you like to run a lot what kind of do you do you use a a good shoe you know what kind of shoes do you use for your running
[doctor] yeah i yeah i i'm starting to get back into it i'm a big new balance person in asics so yeah those are the two brands i like to wear yeah so right now i'm using asics
[patient] okay yeah i like to run too and i use nike
[doctor] okay
[patient] i used to get tumor guy but i i really kinda moved over to nike
[doctor] hmmm
[patient] that's good you know it is running is a great exercise
[doctor] it is
[patient] so have you had any let's get back to the exam here have you had a recent mri of your brain i saw one from a few years ago but as doctor white said anything about getting a more a recent mri
[doctor] yeah she was gon na put one in but she wanted me to see you first and urgently so they have n't called me yet for the mri
[patient] okay so that's good we i think we'll we will follow up with that mri but let's go ahead and take a do a quick physical exam here i reviewed your vitals that the the assistant collected when you came in and everything there looks good including your blood pressure you know with symptoms like that that's one of those things that i'd be concerned about
[doctor] okay
[patient] now on your heart exam it sounds like it's normal sinus rhythm with no murmurs rubs or gallops so that's good as i listen i'm gon na go ahead and look here in your eyes the funduscopic exam shows papilledema and that's just some of swelling behind there in the eye and this let me do a a neurological exam this will take a few minutes you get up to follow my instructions as we go through that okay on neurological exam your cranial nerves one through twelve are intact including a normal cranial reflex and just went to watch you walk across the room here
[doctor] okay turn around come back and okay so on musculoskeletal exam your gait is normal
[doctor] okay go ahead sorry
[patient] that's okay for your first problem your headaches your symptoms are concerning for what we call idiopathic intracranial hypertension and this is a condition that that you have increased pressure in the in your head in your brain without any known cause for it now patient also presents with often present with symptoms such as yours you know headaches worsening with activity ringing in the ears changes in your vision so i'm i'm pretty confident that that's what we're having here now why we get concerned is if the pressure continues to increase this can lead to some permanent changes in your vision so i i do wan na get a a few more tests just so we can confirm that diagnosis and the first one that we just talked about is an mri i think it's really important to get that to check for any other condition that could be contributing to your symptoms now once i have that result i'm gon na be doing also doing a spinal tap which will help me evaluate the pressure in the brain and it can also help you feel better if you do have an increased pressure by taking the decreasing the amount of that pressure just by taking a a a little bit of fluid off of that and lastly i want you to be seen by a neuro-ophthalmologist for a complete eye exam now i i know that sounds like a lot of information but i think it's really important we get that accomplished do you have any questions for me
[doctor] yeah that is a lot and so i i'm sure i'll have more that comes up but so let's say we do all this test and it confirms what you're saying does that mean was i referred to you because that means i will need surgery
[patient] not necessarily if you have idiopathic intracranial hypertension there are number of medications that we can try to help decrease that pressure in your brain and this will also help you have less headaches when you exercise as exercise and weight loss are also an important part of the treatment
[doctor] okay alright alright and i'll probably add something about so is this something i'll be doing soon is this all things i'll be doing this week
[patient] yeah that's a great question here i i'm gon na go ahead and we're gon na for the mri i'll have to get a preapproval from your insurance company i will work on that my my my team in the front office will get that preapproved and then once that's done we'll call you to help schedule that mri
[doctor] okay alright thank you bye
[patient] bye sorry | CHIEF COMPLAINT
Headaches.
HISTORY OF PRESENT ILLNESS
Julie Jenkins is a pleasant 33-year-old female who presents to the clinic today for the evaluation of headaches. The patient was referred from her primary care physician. The patient states that she was seen by Dr. White a few years ago and was going to obtain an MRI; however, Dr. White wanted her to see me first and urgently.
The onset of her headaches began when she was a teenager. Initially, her headaches appeared during menses, however she now experiences them more frequently and with more severity. Her pain is aggravated by physical activities. The patient states that she has been trying to exercise more in order to lose weight, however she is unable to exercise for prolonged periods of time secondary to the headaches. The patient locates her pain to the right side of her head and behind her eye. She describes her pain as a pulsing sensation. She also reports intermittent ringing in her ears for the last few months. Additionally, she reports intermittent blurred vision on the lateral aspect of her vision. She denies any numbness or tingling in her hands, feet, or face.
The patient enjoys running and wears either New Balance or Asics shoes.
REVIEW OF SYSTEMS
Neurological: Reports headaches. Denies numbness or tingling in her hands, feet, or face.
VITALS
Vitals are within normal limits.
PHYSICAL EXAM
CV: Normal head rhythm with no murmurs, rubs, or gallops.
NEURO: Cranial nerves I through XII are intact distally, including a normal cranial reflex.
MSK: Gait is normal.
Funduscopic exam: Positive for papilledema.
ASSESSMENT
Headaches, concern for idiopathic intracranial hypertension.
PLAN
After reviewing the patient's examination today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have recommended that we obtain an urgent MRI of the brain to evaluate for any other condition that could be contributing to her symptoms. We will contact her to schedule this after approved by insurance. Once the MRI results are available for review and further discussion, I will also perform a spinal tap to evaluate the pressure in the brain. I have also advised her to be seen by a neuro ophthalmologist for a complete eye exam. Questions were invited and answered today. The patient agrees to the treatment plan.
INSTRUCTIONS
The patient will follow up with me once the MRI results are available for review and further recommendations. |
D2N115 | aci | [doctor] alright so hey it's nice to see you jack i know you've been experiencing some neck pain could you tell me what happened
[patient] yeah so i was in a a car accident
[doctor] mm-hmm
[patient] and i hit in the back and like my my neck went forward and my head went forward really quick and so i've been having some pain ever since
[doctor] okay and so with this pain how long ago was the car accident
[patient] that was about a week ago
[doctor] okay with this pain like on a scale of one to ten how severe is it
[patient] i would say it's about a seven
[doctor] okay
[patient] it's not a constant pain but like whenever i move my head which is like a lot i i feel it
[doctor] alright so where exactly is it on the side on the back
[patient] it's in the back of my neck
[doctor] okay has anything made it better
[patient] i mean i've tried some ibuprofen that helped a little bit but not too much
[doctor] mm-hmm
[patient] just about five out of ten
[doctor] mm-hmm alright and did you say whether the pain was getting worse
[patient] i mean it's been staying the same it just gets worse when i'm moving my neck
[doctor] okay are you able to turn your neck from side to side
[patient] mostly but there is there is pain with it
[doctor] okay and then do you have headaches
[patient] yeah i had i had a couple early on
[doctor] uh uh
[patient] i have had it lately
[doctor] okay and so does the pain move anywhere like your upper back your shoulder
[patient] no it just stays on monday
[doctor] okay and then any kind of hearing any kind of hearing problems visual disturbances
[patient] no
[doctor] okay have you do have you ever like played sports before or had like a sports accident before
[patient] yeah i played football
[doctor] okay
[patient] years ago but i i did n't have any issues with my neck though
[doctor] okay and then when you got in the car accident did you end up going to the emergency room
[patient] no i mean i i know that going to the emergency room that like the english rides like five hundred bucks so i did n't want to do that
[doctor] i understand i understand okay was there any like swelling or bruising on your neck
[patient] not that i know about no other mag of my neck i really ca n't see that
[doctor] yeah okay no just checking okay so if you do n't mind i'm gon na go ahead and do my physical exam so when i press on here on the side of your neck does it hurt
[patient] yeah a little bit
[doctor] okay positive pain to palpation of the soft tissues of the neck what about when i press on your back or your shoulders
[patient] no that's fine
[doctor] okay so when you flex your neck when you're touching your chin to your chest does that hurt
[patient] mm-hmm
[doctor] alright positive pain with flexion what about when you move it back
[patient] yeah that hurts worse
[doctor] okay okay severe positive pain to extension okay so can you turn your head from side to side does that hurt
[patient] yeah a little bit
[doctor] okay positive pain with rotation and then can you touch your ear to your shoulders
[patient] no
[doctor] okay alright so positive pain on lateral bending wow this is pretty this is pretty serious not serious necessarily sorry about that so i reviewed the results of your x-ray but the results show no signs of fracture or bony abnormalities but let's go ahead and talk about my assessment and plan for you i believe what you have is something called neck strain for your neck pain i sorry treatments we are gon na go ahead and treat this a bit conservatively your i'm gon na put you on anti-inflammatories motrin six hundred milligrams and you're gon na take that every six to eight hours i also wan na give you a muscle relaxant called flexeril and it's gon na be ten milligrams and you'll take that every twelve hours as needed i'm gon na want you to try your best to to like relax your neck i'm sorry not to strain your neck anymore like to be conservative with how you move about and everything like that i also wan na order an mri just because you said you did n't go to the hospital or anything like that i just wan na make sure that you you're not suffering from like a concussion but this is something that's commonly referred to as like whiplash right your head just like it it just wiped essentially like back and forth to so severely and and that's probably what's causing your pain i think i wan na refer you to either physical rehab or a chiropractor once we get the results of the mri just to make sure that there is n't any impingement of like the nerves or anything like that do you have any questions
[patient] i heard the chiropractors will shake they work
[doctor] i do understand that some people have like reservations about going to the chiropractor but you know we do have some good ones that have like longstanding histories and patients that have had positive results from the experience but if you if you do n't like the idea of that we can consider other options like that rehab and physical therapy
[patient] okay
[doctor] alright any other questions
[patient] no
[doctor] alright thank you | CHIEF COMPLAINT
Neck pain
HISTORY OF PRESENT ILLNESS
Jack Torres is a pleasant 40-year-old male who presents to the clinic today for the evaluation of neck pain. The onset of his pain began 1 week ago after he was involved in a motor vehicle accident. He states that he was hit in the back and experienced whiplash. Following the accident he did not present to the emergency room and he does not recall having any swelling or bruising at the neck. He localizes his pain to the posterior aspect of his neck. His pain level is rated at 7 out of 10. When taking ibuprofen he states his pain improves to 5 out of 10. He finds that neck range of motion exacerbates his pain. Initially after the accident he reports that he experienced a couple of headaches, but he states he has not had any recently. He denies any hearing problems or visual disturbances.
SOCIAL HISTORY
Patient reports that he played football years ago without any neck issues.
REVIEW OF SYSTEMS
Eyes: Denies visual disturbances.
HENT: Denies hearing loss.
Musculoskeletal: Reports neck pain.
Neurological: Denies headaches.
PHYSICAL EXAM
NECK: No swelling noted
MSK: Examination of the cervical spine: Positive pain to palpation of the soft tissues of the neck. Shoulders and back are nontender to palpation. Positive pain with flexion, rotation, and lateral bending. Severe pain with extension.
RESULTS
3 views of the cervical spine were taken. These reveal no evidence of any fractures or bony abnormalities.
ASSESSMENT
Neck strain.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed his x-rays did not reveal any signs of a fracture or bony abnormalities. Treatment options were discussed and conservative treatment has been recommended. He will begin taking Motrin 600 mg every 6 to 8 hours. A prescription for Flexeril 10 mg every 12 hours as needed was also provided. He was advised to be mindful of how he moves his neck and to be conservative to avoid straining his neck. I have also recommended that we obtain an MRI for further evaluation as the patient did not go to the emergency room following his accident. He will also be referred to either physical rehab or a chiropractor pending his MRI results.
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D2N116 | aci | [doctor] hey hi bobby how are you doing
[patient] i'm doing good how are you
[doctor] i'm doing fine so i understand you're here having some left or some right shoulder pain that you've had for a few weeks now
[patient] yeah it was i was doing some work in my backyard and a lot of different projects going on and you know i was obviously sore all over the next couple of days but my my right shoulder just keeps on bothering me and it keeps it's just really sore and it just has n't been going away
[doctor] okay so have you had ever had any pain in that shoulder before
[patient] a little bit i you know i i hurt that same shoulder because it's my my dominant hand my right hand i hurt it playing baseball when i was younger
[doctor] mm-hmm
[patient] so i've always had a little bit issues but this is it's does n't feel like it's in the rotator cuff it's it's kinda more on the outside and it's kinda like it's more tender on the outside when i raise my arm up so
[doctor] okay yeah are you able to move your arm very well or not
[patient] yeah there is no restriction with my arm it just i definitely feel some pain on the outside of it
[doctor] okay and are you having pain all the time or just or does it come and go
[patient] just whenever i move it if i'm sitting still i really do n't notice anything but whenever i move it then i can definitely feel some pain
[doctor] okay how about at night is it bothering you at night also
[patient] a little bit because i sleep on that side so
[doctor] okay
[patient] of course
[doctor] okay and i may miss did you say what have you been taking for pain for that
[patient] i just been taking some advil and then icing as much as i can so that's about it
[doctor] okay and does that seem to help or
[patient] a little bit yeah a little bit i mean it's it's still like you know sore to touch but it definitely dulls it a little bit
[doctor] well sounds like you have quite a few projects going on what all what all are you doing for for your yard and
[patient] i well let's see i've been putting an outdoor shower in we're extending our patio putting making some flower boxes putting down some you know for stone and all the flower beds so my wife's really put me to work i got a laundry lift
[doctor] wow it sounds like a variety of projects but if you're putting down stone you're probably lifting those as well and then
[patient] yeah
[doctor] yeah i bet that is sore now tell me this have you experienced any numbness in your arm or your hands or
[patient] no not really no numbness that i can think of
[doctor] okay alright so see i'm gon na i'd like to do just a quick physical exam and i've reviewed your vitals those look good your no fever so that's good you're ninety seven . eight and your heart rate looks good at sixty two respirations sixteen your blood pressures one sixteen over eighty four that looks fine your oxygen saturation is real good at ninety nine percent so that all looks good so let's take a look at your left at your right shoulder so you have limited active and passive range of motion and there is some tenderness at the great tuberosity of the humerus there is no tenderness at the sternoclavicular or acro acromioclavicular joints you do have a good hand grip okay and on neurovascular exam of your right arm your capillary refill is less than three seconds and your sensation to touch is intact so i've reviewed the results of your shoulder x-ray and there is no fracture so that's good so let me tell you a little bit about my assessment and plan so for your first problem the left shoulder pain your symptoms are most likely due to this rotator cuff rotator cuff tendinopathy that means you that you injured injured the tendons of the muscles that help make your shoulder muscles i think we had to go ahead and order just an mri since you have had some problems before as well to make sure there's nothing else going on with it and i also want to refer you to physical therapy for approximately six to eight weeks and so during that time continue the tylenol and if your symptoms do n't improve we can go ahead and consider a steroid injection of your shoulder which could provide some relief do you have any questions about your plan
[patient] no that sounds good
[doctor] okay alright yeah a lot of patients it's very successful with the physical therapy so i really hope that will do it and so we'll just start there okay
[patient] sounds great
[doctor] okay thanks
[patient] thanks
[doctor] did you have any other any other problems any other injuries that that went along with this or
[patient] my both my my feet are actually really sore too i obviously have been doing a lot of other yard work so you know it's kinda it's really stiff and stuff and they you know my ankle joints as well my wife seems to think that i do n't drink enough water so it could be something along that lines but i do n't know they're kinda this they just they're really sore and stuff so i've been trying to put them up and kinda put ice on them keep them elevated and it seems to be helping out a little bit but
[doctor] yeah so if you do n't feel that you did anything to injure it we might start just maybe do some epsom salts have you tried soaking your feet in epsom salts that will tend to kinda pull out what's going on in there and just help your those muscles to relax and the soreness to to go away you might try that
[patient] okay that sounds like a plan that sounds good | CHIEF COMPLAINT
Right shoulder pain.
HISTORY OF PRESENT ILLNESS
Bobby Flores is a 56-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of right shoulder pain.
The onset of his pain began a few weeks ago, when he was performing different projects in his backyard. He states that he was sore all over the next couple of days. He locates his pain to the lateral aspect of his right shoulder. His pain is aggravated with movement. The patient denies any restriction with his arm. He also reports pain at night when he sleeps on his right side. The patient denies any numbness in his arm or hands. He has been taking Advil and icing his shoulder, which provides some relief. The patient reports a history of right shoulder pain when he was younger while playing baseball.
The patient also has complaints of bilateral foot and ankle pain. He attributes this pain to the yard work he has been doing. For treatment, he has iced and elevated them, which provided some relief.
REVIEW OF SYSTEMS
Musculoskeletal: Positive for right shoulder pain.
Neurological: Negative for numbness in hands.
VITALS
Temperature: 97.8 degrees F.
Heart Rate: 62 BPM.
Respirations:16.
Blood pressure: 116/84 mm Hg.
Oxygen saturation: 99 percent on room air.
PHYSICAL EXAM
CV: >Capillary refill is less than 3 seconds.
NEURO: Normal sensation. Neurovascularly intact on the right. Sensation to touch is intact on the right shoulder.
MSK: Examination of the right shoulder: Limited active and passive ROM. Tenderness at the greater tuberosity of the humerus. No tenderness at the sternoclavicular or AC joints. Good hand grip.
RESULTS
3 views of the right shoulder were taken. These reveal no fracture or dislocation. No abnormalities noted.
ASSESSMENT
1. Right shoulder rotator cuff tendinopathy.
2. Bilateral foot pain.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the right shoulder to evaluate for a possible rotator cuff tear. I have also recommended that the patient attend formal physical therapy for 6 to 8 weeks. He can continue taking Tylenol as needed for pain. If his symptoms do not improve with physical therapy, I will recommend a cortisone injection.
In regards to his bilateral feet pain, I have recommended that we treat the patient conservatively. I am recommending the patient soak his feet in an Epsom salt soak as well as elevate as needed.
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D2N117 | aci | [doctor] mister jackson is a 45 -year-old male who has a history of diabetes type two and mild intermittent asthma and he is here today with right elbow pain so hey there mark nice to see you again listen sorry you're having some elbow pain let's talk about it but i would like to record this conversation with this cool app that i'm using that's gon na help me focus on you a bit more would that be alright with you
[patient] yeah that sounds great
[doctor] okay great so mark tell me about your right elbow pain what's been happening
[patient] so yeah i've been playing a lot of tennis recently buddy of mine you know you're always telling me to get off the couch and be more active so a buddy of mine asked me if i wanted to go play tennis he just joined a country club i've been hitting hitting the cord a lot more and it's just been killing me for the last three weeks or so
[doctor] okay alright and where in your elbow is it hurting
[patient] outside part
[doctor] hmmm okay does the pain radiate anywhere like down to your arm up to your shoulder or anywhere else
[patient] no it does n't
[doctor] okay and what would you say the pain is you know on a scale of zero to ten
[patient] it's probably an eight when i'm just when i'm using it even if it's to get something out of the cupboard and it's a three when i'm just kinda resting
[doctor] hmmm okay and do you would you say it's a sharp pain stabbing pain aching throbbing how would you describe it
[patient] all of the above shooting stabbing very sharp
[doctor] okay alright and you let's see other than the the tennis you know increase in tennis activity you have n't had any trauma recently falling on it or you know felt a pop anywhere or anything like that have you
[patient] not that i can recall
[doctor] okay and and you said it's it's worse with movement better with rest is there anything else that makes it makes it worse or makes it better
[patient] i've taken some tylenol and ibuprofen but as soon as those wear off it it comes right back so they do n't really help
[doctor] okay
[patient] and i did try a little ice i probably should ice it more but i did n't notice it helping much
[doctor] okay okay alright yeah well i definitely i'm glad you're getting some exercise now that's good for your diabetes and all that and out there playing tennis kinda back back to the back to the old days for you right did do i recall that were n't you a big tennis player back in the day like state champ in high school or something
[patient] yeah yeah that was a hundred years ago i ca n't i i try to play like that and i ca n't i ca n't do that anymore but yeah a good memory that's a that's a good memory
[doctor] now
[patient] kind of a tennis guy too right did you see the the australia open
[doctor] i did i did yeah that was that was crazy that was a great tournament what a what a finish unbelievable
[patient] yeah hey did you see the masters i know you're a golfer
[doctor] yeah yeah yeah i do n't get out as often as i as as i like to but but the masters yeah that was that was amazing that was lot of fun to lot of fun did you catch it too
[patient] i did
[doctor] yeah
[patient] yeah
[doctor] yeah
[patient] but that's it was i i could n't believe tiger went out there of course he did
[doctor] right
[patient] it was cool to see nothing
[doctor] yep yep agreed agreed and so well listen we'll we'll hopefully get you feeling better here and get you back out on the court and out on the course and we'll talk about that but let's let me ask you about your diabetes a little bit a little bit here so how have your blood sugars been running mark have they been what in the low one hundreds two hundreds where are they
[patient] they are like one fifty one sixty you know we just had easter and my kids got a whole bunch of candies so i keep eating that
[doctor] hmmm okay yeah yeah understood so those cadboy eggs they'll get you every time too right
[patient] yes
[doctor] boy my gosh yeah those are the best so those are those are deadly do n't tell my cardiologist so okay so listen you know i see that we have you on metformin five hundred milligrams once a day no actually last visit we increased it so i've got you on metformin five hundred milligrams twice a day correct you're still taking that
[patient] yes twice a day
[doctor] okay and but your blood sugars are a bit off you know maybe those the cadberry eggs so how about your asthma how has that been doing you know have you had any asthma attacks you're still taking flovent twice a day and the albuterol as needed
[patient] yeah knock on wood i my asthma is pretty much under control
[doctor] okay excellent excellent alright and i recall you know just kinda review a few things i i think you've got an allergy to penicillin is that correct
[patient] that's correct yes
[doctor] okay and then you you know your surgical history you had your your gallbladder out what about ten years ago i think by doctor nelson correct
[patient] yes that's right
[doctor] okay and then let's go ahead and examine you alright so mark your exam is pretty much you know for the most part normal with a few exceptions on your heart exam you still have a grade three out of six systolic ejection murmur and that's unchanged from prior exam we're watching that and so that just means i hear some some heart sounds as your heart is beating there i'm not too concerned about it as as that's not changed otherwise normal cardiovascular exam and your physical exam otherwise on your musculoskeletal exam on your right elbow you do have moderate lateral epicondylar tenderness of the right elbow and how about when i move this when i move your elbow like this does that hurt you
[patient] kills
[doctor] okay sorry about that so you've got moderate pain with passive range of motion of the right elbow there is no palpable joint effusion and now what if i press against your wrist like so does that hurt you
[patient] yeah it hurts a little bit
[doctor] okay alright sorry so that's you have mild pain with resisted extension of the right wrist as well okay otherwise normal unremarkable exam and let's talk about your results now so your right elbow x-ray today shows no acute fracture or other bony abnormality so that's good there's no malalignment or sign of joint effusion and otherwise it's a normal right elbow x-ray so that's reassuring okay and hey you know i meant to ask you you know and do you have any history of fever recently you know along with the elbow pain you had noticed a fever
[patient] no i do n't think so
[doctor] okay great excellent alright so tell you what let's let's talk about my assessment and your plan here so for your first problem my assessment is is that you have acute lateral epicondylitis of your right elbow and this is also known as tennis elbow go figure right so this is due to overuse likely the increase in your your tennis activity which normally would be good but maybe we're overdoing it a little bit so i have a few recommendations i'd like you to rest your right arm as much as you can i want you to stop tennis for the next four to six weeks and please avoid repetitive stress in that right arm as well i want you to ice that right elbow for twenty minutes at least three times per day and this should reduce the pain and inflammation and then i'm also going to give you a brace for your right forearm and my nurse will give this to you before you leave that should help with the discomfort okay in that right elbow i will also write you a prescription for ultram and this should help with the pain i'll write you a prescription ultram fifty milligrams once per day that should help with your elbow pain so then i wan na see you in follow-up in four weeks and so we'll reevaluate your elbow at that time and if you we'll consider some additional imaging if needed possibly a physical therapy referral depending on how you're doing mkay now for your second problem of diabetes type two my assessment is is that your blood sugar is a little bit out of control mkay so we need to make some adjustments i'm going to increase your metformin to one thousand milligrams twice per day and i want you to check your blood sugar twice daily for the next two weeks and then let me know how your blood sugar is running and we can make some additional adjustments if needed but i will increase your metformin to one thousand milligrams twice a day now i'm going to also order a hemoglobin a1c level and and a cbc blood test today and and so we'll check those results the hemoglobin a1c and the cbc and then i'm going to also check a chem-12 blood test as well and now for your third problem of the mild acute intermittent asthma you my assessment is that it really remains under good control so let's keep you on that flovent and the albuterol no changes there and you can use those as tolerated it does look like you need a refill on your albuterol so i'm gon na write you a prescription for a refill of the albuterol and you can pick that up at your pharmacy as well so how does that all sound any questions for me
[patient] it sounds pretty good i ca n't believe it's just tennis elbow feel like a looser coming in here but it's okay i get it
[doctor] yeah yeah well
[patient] i'm not i'm not young anymore
[doctor] yeah well let's let's keep you active but take a break for a bit and let's ease back into it okay so it's great to see you and i'll see you back in four weeks let me know if you have other problems in the meantime
[patient] okay | CHIEF COMPLAINT
Right elbow pain.
MEDICAL HISTORY
Patient reports history of type 2 diabetes and mild intermittent asthma.
SURGICAL HISTORY
Patient reports history of cholecystectomy 10 years ago by Dr. Nelson.
SOCIAL HISTORY
Patient reports he has been playing tennis since high school.
ALLERGIES
Patient reports that he has an allergy to PENICILLIN.
MEDICATIONS
Patient reports taking metformin 500 mg twice a day, Flovent twice a day and albuterol as needed.
REVIEW OF SYSTEMS
Constitutional: Denies fever.
Musculoskeletal: Reports right elbow pain.
PHYSICAL EXAM
Cardiovascular
- Auscultation of Heart: Grade 3 out of 6 systolic ejection murmur, unchanged from prior exam.
Musculoskeletal
- Examination of the right upper extremity: Moderate lateral epicondylar tenderness. Moderate pain with passive range of motion. No palpable joint effusion. Mild pain with resisted extension of the right wrist.
RESULTS
X-ray of the right elbow taken today is reviewed and shows no acute fracture or other bony abnormality. There is no malalignment or joint effusion. Otherwise normal right elbow x-ray.
ASSESSMENT AND PLAN
1. Acute lateral epicondylitis of right elbow.
- Medical Reasoning: Patient presents today with symptoms consistent with lateral epicondylitis secondary to overuse.
- Patient Education and Counseling: The nature of the diagnosis was discussed. He was advised that this is like due to increased tennis activity and was encouraged to rest as much as possible. - Medical Treatment: Patient will discontinue playing tennis for the next 4 to 6 weeks, as well as avoid repetitive stress with the right arm. He will apply ice to the elbow for at least 20 minutes 3 times per day to reduce pain and inflammation. Right forearm brace was provided today to help with discomfort. Prescription for Ultram 50 mg once per day was also provided for pain.
2. Diabetes type 2.
- Medical Reasoning: His blood sugar today is not controlled.
- Patient Education and Counseling: We discussed that I would like him to take his blood sugars twice a day for the next 2 weeks and to let me know how they are running so we can make additional adjustments if needed.
- Medical Treatment: He will increase his metformin to 1000 mg twice a day. He will begin home blood sugar monitoring twice a day for the next 2 weeks. Hemoglobin A1c, CBC, and a Chem-12 test were ordered today.
3. Mild acute intermittent asthma.
- Medical Reasoning: This remains well-controlled.
- Medical Treatment: The patient will continue his Flovent twice a day. Refill of albuterol provided today to be used as needed.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow-up in 4 weeks to assess his elbow and to determine if additional imaging or physical therapy is needed. |
D2N118 | aci | [doctor] alright so how're you doing today angela
[patient] i'm doing pretty well
[doctor] alright so looking here at your appointment notes it says you're you're here you think you have a kidney stone you had some in the past so we're gon na take a look at that and then you also have a past medical history of hypertension and diabetes we want to take a look at those as well so first thing what's going on with your kidneys you as what how long ago have you been feeling pain and and how's all that
[patient] pain's been up and down i went to the emergency room last week but now i think i'm doing a little bit better
[doctor] okay so the case of kidney stones so have you had you said you've had them in the past and how often would you say
[patient] i do n't know i this is probably like my seventh or eighth kidney stone
[doctor] seven or eight kidney stones so do you think you passed it yet or is it still in the
[patient] i think this one passed yeah
[doctor] this one passed how long would you say it took to
[patient] well i went last week and then i think it passed about three days ago
[doctor] okay so are you still noticing any blood in your urine
[patient] no no more blood
[doctor] alright are you still having pain
[patient] nope
[doctor] yeah
[patient] the pain's gone
[doctor] okay that that's that's that's really good did they do anything for you at the hospital giving you any medications
[patient] they gave me some pain medicine
[doctor] okay do you remember what it was
[patient] i think it was percocet
[doctor] okay well that's good i'm very glad to see that you were able to pass that stone have you seen a urologist before about this
[patient] i have n't seen one in a while but yes i saw someone maybe a year ago
[doctor] okay so yeah i know you keep having these recurrent kidney stones so i definitely think we can get you a referral to urology just to check up on that and also wan na do some labs as well
[patient] okay
[doctor] so i also see you're here for you have a past medical history of of hypertension and when you came in today your blood pressure was a little bit high it was a one fifty over ninety i'm reading here in your chart you're on two point five of norvasc
[patient] hmmm
[doctor] now have you been taking that regularly
[patient] i have but at home my blood pressure is always great
[doctor] okay maybe you have a little white coat syndrome some of my patients do have it i have it myself and i'm a provider so i definitely understand yeah i know we we talked about last time you getting a blood pressure cuff and taking those about two to three times a week so what have those readings been i'm usually like one thirty to one forty over sixty to seventy
[patient] okay
[doctor] that's that's that's not too bad i think when you first came in you were around like one eighty so it seems to be that that norvasc is is working for you how about your diet i know you were having a little issue eating some fast food and and cakes and cookies and have you been able to get that under control
[patient] yeah it's hard to give up the fast food altogether because it's a lot of on the go you know
[doctor] okay so do you think you would be able to get that under control by yourself or would you do you think you would need help with that maybe a dietitian be able to help you out
[patient] yeah i do n't know i do n't know if i can make another appointment i just add to the extra
[doctor] okay
[patient] less time to make food so
[doctor] yeah yeah definitely understand
[patient] mm-hmm
[doctor] alright yeah so i mean that's one thing we just got ta work one is your diet we try to keep you at least just twenty three hundred milligrams or less of sodium per day i know that's hard for a lot of salads and stuff i know it's hard for lot of people especially with all like the the prepackage foods we have around today so that's definitely something we we should work on
[patient] mm-hmm
[doctor] so let's also look here you have a history of diabetes and so you're on that five hundred milligrams of metformin daily now have you been taking that as well
[patient] yeah i take my metformin
[doctor] okay
[patient] yeah
[doctor] so what have your blood sugars been running daily
[patient] well i do n't check it very often
[doctor] okay
[patient] but i think they've been pretty good
[doctor] okay so i'm looking here i think last after your last visit you got a1c now was six . seven so it's a little bit high it's gone down a little bit since you were first diagnosed with the type two diabetes a year ago so i'm glad we're making progress with that as well alright so i'm just gon na do a quick physical exam on you before i do just wan na make sure are you having any chest pain today
[patient] no
[doctor] alright any any belly pain
[patient] no
[doctor] alright so i'm gon na listen to your lungs your lungs are clear bilaterally i do n't hear any crackles listen to your heart so on your heart exam i do hear that grade two out of six systolic ejection murmur and we already knew about that previously so it has n't gotten any worse so that's good so i'm gon na just press here in your abdomen because that you did have those kidney stones does that hurt
[patient] no
[doctor] alright i'm gon na press here on your back
[patient] no pain
[doctor] okay so on your abdomen exam of your abdomen i'm showing no tenderness to palpation of the abdomen or tenderness of the the cva either on the right side so that that's good i think that's pretty much cleared up so let's we'll talk a little bit about my assessment and plan for you and so my assessment you you did have the those kidney stones but i i think they are passed this time but i do want to get a couple of labs so we'll get a urinalysis
[patient] okay
[doctor] alright we'll get a urine culture just to make sure everything is is cleared up i also want to give you a referral to referral referral to urology
[patient] okay
[doctor] because you do keep having these all the time and so maybe there's something else going wrong and so they can help get that under control
[patient] can i see doctor harris
[doctor] of course yeah we can we can get you that road to doctor harris and
[patient] he's not like
[doctor] he's great he's he's he he he's great i've heard he does really good work so that'll be good so for the hypertension you seem to be doing well on the two . five of norvasc so we are not gon na make any changes to that do you need any refills right now
[patient] no usually the pharmacy just sends them through when i call
[doctor] okay great so we we wo n't we gave you refills with that i do wan na give you a consult to nutrition
[patient] okay
[doctor] just to help you with that diet
[patient] okay
[doctor] because i think that's a major factor of us eventually getting you off of all medications
[patient] hmmm
[doctor] and then for your diabetes i'm just keep you on that on that five hundred of metformin okay i think you're doing well with that as well also but i do want you to start taking your blood sugars if you can take them before every meal
[patient] okay
[doctor] just to gauge where you are so you can tell how much food you should actually be be eating
[patient] okay
[doctor] alright
[patient] i can try that
[doctor] so how does that that sound
[patient] that sounds like a plan when should i come back and see you
[doctor] so you can you can come back in three months and we'll check up again i forgot you did tell me last time that you were having some issues with insomnia
[patient] hmmm
[doctor] how is that going for you is it still happening
[patient] i mean sometimes i stay awake just kinda worrying about things but but i've tried some meditation apps and that helps
[doctor] okay alright and i know we talked a little bit before about practicing proper sleep hygiene you know just making sure that all of your electronics are off you know dark room
[patient] yeah
[doctor] cool room have you been doing that
[patient] well i do like to sleep with the tv on and my phone is right by my bed because i never know if someone's gon na call me you know
[doctor] yeah i i know i'm like apple i do n't know if you have an iphone or not but i know apple has this the the sleep mode now do that disturbance so you put that on
[patient] it's a good idea
[doctor] interrupt you
[patient] yeah
[doctor] okay have you tried taking melatonin to sleep
[patient] i used it a couple times but but it did n't seem to help that much
[doctor] okay how about i do n't think i've prescribed you anything yet do you think you would need anything
[patient] hmmm i do n't really wan na take any sleeping pills
[doctor] okay that's understandable alright so for the last issue for the insomnia i'm just gon na have you take ten milligrams of melatonin as needed
[patient] okay
[doctor] and just try i guess the best as possible to practice the proper sleep hygiene so you can get to sleep at night and and feel pretty rested
[patient] okay
[doctor] alright
[patient] mm-hmm
[doctor] so do you have anything any other questions for me
[patient] no that's all
[doctor] alright so we will see you in three months
[patient] okay sounds good
[doctor] alright
[patient] like | CHIEF COMPLAINT
Kidney stone.
MEDICAL HISTORY
Patient reports history of hypertension, diabetes, and kidney stones.
MEDICATIONS
Patient reports taking Norvasc 2.5 mg and metformin 500 mg.
REVIEW OF SYSTEMS
Constitutional: Reports insomnia.
Cardiovascular: Denies chest pain.
Gastrointestinal: Denies abdominal pain.
Genitourinary: Denies hematuria.
VITALS
Blood pressure: 150/90 mm Hg
PHYSICAL EXAM
Respiratory
- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.
Cardiovascular
- Auscultation of Heart: Grade 2/6 systolic ejection murmur, unchanged.
Gastrointestinal
- Examination of Abdomen: No masses or tenderness. No tenderness of the CVA.
RESULTS
A1c: 6.7
ASSESSMENT AND PLAN
1. Kidney stones.
- Medical Reasoning: Patient recently experience an episode of kidney stones which is her 7th or 8th episode. Based on the patient's symptoms and exam today, I think she has likely passed her kidney stones.
- Patient Education and Counseling: I advised the patient that we will obtain further testing, however, based on her recurrent episodes a referral to urology is necessary.
- Medical Treatment: Urine culture and urinalysis were ordered. She will be referred to Dr. Harris in urology.
2. Hypertension.
- Medical Reasoning: Patient is currently stable and doing well on Norvasc 2.5 mg.
- Medical Treatment: Continue Norvasc 2.5 mg. Referral to nutrition provided.
3. Diabetes.
- Medical Reasoning: Patient is currently stable and compliant with her metformin.
- Patient Education and Counseling: She was advised to start checking her blood sugar prior to every meal.
- Medical Treatment: Continue metformin 500 mg daily. Start daily blood sugar monitoring before each meal.
4. Insomnia.
- Medical Reasoning: The patient has a history of insomnia.
- Patient Education and Counseling: We discussed proper sleep hygiene.
- Medical Treatment: I have recommended she take 10 mg of melatonin as needed.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
Patient will return for follow-up in 3 months. |
D2N119 | aci | [doctor] hey betty how are you doing
[patient] i'm doing okay i just been really frustrated because with my asthma and it just seems like i can never catch a break never get better i'm always it seems like i'm always coughing and wheezing
[doctor] i'm sorry to hear that what normally triggers your asthma type symptoms
[patient] i find that it's really really when i get sick if i get sick with a cold i almost always know that my asthma is going to flare i did notice one time though that when i went to my aunt's house i i had a flare afterwards and i think it's because of her cat so i try to avoid going there and i have n't really had an issue since
[doctor] okay so now you mentioned that that happens somewhat a lot how frequently does this occur that you have these breathing type problems
[patient] it seems like it happens really every month or every other month for the past six months i usually end up going to the urgent care a lot and get or my primary care doctor and so sometimes they'll give me antibiotics sometimes i'll get steroids one time it was so bad i actually ended up going to the emergency department
[doctor] wow that that can be a little bit scary so you mentioned that your primary care provider or the urgent care provider gave you medications what medications are you using for your asthma right now
[patient] i have two inhalers one but i really just use one of them it's a blue one that seems like the only inhaler that helps me the other one when i when i try to use it it does n't work
[doctor] okay so do you think that's the albuterol inhaler is it do you remember the name like ventolin or
[patient] yes yes that's the name of it
[doctor] is that it okay alright and then how often do you feel like you need to use that
[patient] i would say like almost everyday i feel like i'm using my inhaler because i'm always coughing and wheezing and a couple of times a night i'll wake up as a couple times a week i'll end up waking up needing to use my inhaler as well
[doctor] okay and then when you use it at that time does it help
[patient] it does
[doctor] okay and how many walk me through how you use that you just wake up and you take one puff or is it two puffs
[patient] yeah i take i usually take two puffs
[doctor] okay but then you get enough relief that you can go back to sleep
[patient] yeah for the most part
[doctor] okay now have you ever needed to be hospitalized due to your asthma symptoms you mentioned you've had to go to the er
[patient] yeah for only once i can think of when i was young i think like around eight years old i had to be hospitalized but nothing since then
[doctor] okay i do wan na take a little bit of a a deeper dive here into your er and urgent care visits can you tell me a little bit more about those
[patient] yeah i feel like i've had several i do n't remember the exact number but i've had several this past year they almost always have to start me on prednisone
[doctor] okay like a prednisone taper pack that type of thing
[patient] yeah yeah sometimes they'll just give me like like a like a large dose over five days
[doctor] okay
[patient] and then sometimes they make me take less and less and less so the over like nine or ten days
[doctor] okay so both the dosepak and then also the high dose as well okay
[patient] yeah
[doctor] and then when was your last exacerbation
[patient] probably about a month ago
[doctor] okay so just out of curiosity you mentioned that you you have trouble when you go over to your aunt's house because of your cat now i see here that you really like to go outside and walk and do those type of things do you have any other type of issues whenever you you go outside any any seasonal allergies or anything like that
[patient] no not really
[doctor] okay so you do n't have any history of seasonal allergies which is good so it looks like here that you put down that you enjoyed hiking so you do n't have any trouble getting out and going hiking and and have you tried the new trails there behind behind the wreck center
[patient] yeah i'm really excited to i mean i have to be careful because i you know with my coughing my wheezing but i'm really i'm looking forward to getting better so i can really start hiking again
[doctor] okay now i really need you to be truthful when you answer these next questions this is important for taking a good history do you smoke any type of cigarette or tobacco product and have you ever smoked or do you smoke marijuana on a regular basis
[patient] no i've never smoked and i do n't vape either or yeah i do n't smoke cigarettes or marijuana
[doctor] okay and then you said you do n't vape so no vaping or e-cigarette use at all
[patient] hmmm hmmm
[doctor] okay and then are you routinely in an area where there is a lot of airborne particular like smoking in bars or around any type of of you know like race tracks or anything like that
[patient] sometimes i go to the bars with some friends and yeah the smoking does irritate me
[doctor] okay
[patient] so i do n't try to go there often
[doctor] okay thank you for sharing that with me so if it's okay with you i'd like to go ahead and do a quick physical exam
[patient] okay
[doctor] now i reviewed your vitals for today and your your blood pressure is good it's one twenty eight over eighty two your respiratory rate is sixteen and your oxygen saturation is ninety nine percent on room air which is a good thing i'm gon na take a listen to your heart here your heart is regular rate and rhythm and i do n't appreciate any ectopic beats or and i do n't hear anything like rubs murmurs or gallops which is good so i'm gon na go take and listen to your lungs here on your lung exam i do appreciate some diminished lung sounds throughout with the occasional slight expiratory wheeze and that's bilaterally so i hear that on both sides i'm gon na go do a quick neck exam here neck is supple trachea is midline i do n't appreciate any lymphadenopathy taking a listen here i do n't appreciate any carotid bruit now i'm also gon na take a look at your hands here i note strong bilateral pulses i do n't appreciate any clubbing on any of your fingertips which is which is important and i also note brisk capillary refill i'm gon na go ahead and review the results of your pulmonary function test that i had you do when you came into the office today and reviewing those results i do see that they are consistent with somebody who would be diagnosed with asthma so lem me go ahead and tell you a little bit about my assessment and plan so now for your first problem of asthma your symptoms are consistent with moderate to intermediate or i'm sorry moderate moderate intermittent asthma and it's gon na be really important for us to be consistent with your inhaled inhaled steroid inhaler so i'm gon na need you to take that as prescribed and that's really gon na help cut down on those daily symptoms and needing to use that rescue inhaler that albuterol inhaler as frequently so the more you take and more consistently you take your inhaled steroid inhaler the less you will use your albuterol now it's not a fast acting inhaler like your albuterol but what is important is as going to be what helps you long term now if you do have an acute exacerbation so if you're having an acute issue with your breathing i do want you to continue to use your albuterol inhaler one to two puffs and then i want you to wait and see how your breathing is before you would take an additional one to two puffs we hope you have less of those acute exacerbations as you continue to use your inhaled steroid i'm also going to put together an asthma action plan for you and that's gon na help us look at your symptoms see where your your pain points can be you know like those being having issues with with cats or dust that type of thing and we'll work on how to handle those symptoms through that asthma action plan so do you have any questions comments or concerns otherwise i will see you in thirty days
[patient] alright thank you
[doctor] you're welcome
[doctor] so let me tell you a little bit about my assessment and plan for your first problem of asthma your symptoms are consistent with moderate intermittent asthma i'm gon na start you on flovent one hundred ten micrograms one puff twice per day that's gon na be important for you to be consistent with your inhaled steroid inhaler this is gon na help prevent those daily symptoms and from needing for you to use your albuterol inhaler or that rescue inhaler less frequently you can continue using your ventolin inhaler and that would be two puffs every four to six hours p.r.n . i'm also gon na put together an asthma action plan for you so we know what to do based on your symptoms i'd like to see you again in a month or sooner if you have any worsening symptoms does that sound okay
[patient] it does thank you
[doctor] you're welcome i'll see you in a month
[patient] alright thanks | CHIEF COMPLAINT
Asthma.
MEDICAL HISTORY
Patient reports history of asthma.
SOCIAL HISTORY
The patient denies the use of any type of cigarette or tobacco product, as well as marijuana. Occasionally, she will be at a bar that allows smoking inside, which does bother the patient. She enjoys being outside and hiking.
ALLERGIES
Denies seasonal allergies.
MEDICATIONS
Patient reports using an albuterol inhaler, 2 puffs.
REVIEW OF SYSTEMS
Respiratory: Reports coughing and wheezing.
VITALS
Blood pressure: 128/82 mm Hg.
Respiratory rate: 16
O2 saturation: 99% on room air.
PHYSICAL EXAM
Neck
- General Examination: Neck is supple without lymphadenopathy. Trachea is midline. No carotid bruit.
Respiratory
- Auscultation of Lungs: Diminished lung sounds throughout with the occasional slight expiratory wheeze, bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No ectopic beats. No rubs, murmurs, or gallops.
Musculoskeletal
- Examination: Strong bilateral radial pulses. No clubbing. Brisk capillary refill.
Hematology/Lymphatic/Immunology
- Palpation: No enlarged lymph nodes.
RESULTS
Pulmonary function test obtained today is reviewed and findings are consistent with asthma.
ASSESSMENT AND PLAN
1. Moderate intermittent asthma.
- Medical Reasoning: The patient's symptoms and results of her PFT are consistent with moderate intermittent asthma.
- Patient Education and Counseling: I explained the importance of consistency with her daily inhaler as this will help prevent daily symptoms and the need to use the albuterol inhaler as frequently. My hope is that she has less acute exacerbations as she continues to use her inhaled steroid.
- Medical Treatment: Prescribed provided for Flovent 110 mcg 1 puff twice per day. She can continue using her Ventolin inhaler 2 puffs every 4 to 6 hours as needed. I have recommended using her albuterol inhaler 1 to 2 puffs and then monitor her breathing prior to taking an additional 1 to 2 puffs. I am also going to put together an asthma action plan for her so we know what to do based on her symptoms.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up in 1 month for reevaluation or sooner for worsening symptoms.
|
D2N120 | aci | [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 | HISTORY OF PRESENT ILLNESS
Larry Garcia is a pleasant 41-year-old male who presents to the clinic today for the evaluation of back pain.
The onset of his pain began 2 years ago, after moving furniture. He denies any specific injury. The patient describes his pain as sharp and stabbing. He locates his pain to his lower back, which radiates distally into his right leg and occasionally into his great toe. Sitting will increase his pain and he notes he is unable to get comfortable. The patient also reports numbness and tingling, especially in his right leg that radiates distally to his foot. He adds that he tries to be as active as he can, however it has been difficult with his back pain. The patient adds that he has gained weight over the past year. He denies any loss of sensation in his genital or rectal area, weakness, or loss of bladder or bowel control.
In the past, he has attended physical therapy. The patient has also been prescribed pain medications, however they only provided temporary relief. He would like to avoid any surgical procedure at this time.
SOCIAL HISTORY
He quit smoking 20 years ago.
FAMILY HISTORY
The patient denies any family history of spine conditions.
REVIEW OF SYSTEMS
Constitutional: Reports weight gain.
Musculoskeletal: Reports lower back pain.
Neurological: Positive for numbness and tingling in the right leg and foot. Denies loss of bowl or bladder control, or loss of sensation in the genital or rectal area.
VITALS
Vitals are within normal limits.
PHYSICAL EXAM
NEURO: Decreased sensation to light touch at the right lateral thigh at the L4 dermatome. Patellar and Achilles reflexes are symmetrical.
MSK: Examination of the lumbar spine: No overlying erythema or ecchymosis. Midline tenderness at L4-5 disc space with right-sided lumbar paravertebral tenderness. Pain with lumbar flexion. Supine straight leg test is positive.
RESULTS
The MRI of the lumbar spine was reviewed today. This revealed a disc herniation with nerve impingement.
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. |
D2N121 | aci | [patient] hi kenneth how are you the medical assistant told me that you had some knee pain yeah i was getting ready for the holiday weekend and i was out on my boat skiing and i i did a jump and kinda twisted when i landed and my knee has been hurting me ever since
[doctor] okay so that was about five days ago then
[patient] yeah yeah that was last weekend
[doctor] last weekend okay now which knee is it
[patient] it's my right knee
[doctor] your right knee okay and i know that it sounds like you were on a motor boat as you were you know water skiing but did you hear anything pop or feel anything pop when it happened
[patient] no it just felt like something stretched and then it swelled up some afterwards
[doctor] okay and were you i assume that you were were you able to get out of the water by yourself or did you need some assistance
[patient] i was able to get out but it was very sore to climb up and you know any kind of squatting or bending is really pretty sore
[doctor] yeah okay and have you ever injured this knee before
[patient] no that was the first time
[doctor] that was the first time okay where do you have a boat what lake do you have it on lake
[patient] lake martin
[doctor] okay nice and so you're a frequent water skier
[patient] yeah i try to go every weekend when we can
[doctor] that's nice very very good are you looking forward to spring are you a baseball fan are you excited by opening day
[patient] no i'm not a baseball fan but i love spring and chicken time of year launds of outdoor activities nice nice i'm i'm not really a baseball fan either but my husband makes me watch the the meds all the time and they lose all the time so he is always upset so so anyway
[doctor] yeah right so how about your high blood pressure how are you doing with that are you taking your blood pressure medication like i asked
[patient] i'm taking it everyday and i check my blood pressure at home and it's been about one twenty five over eighty most of the days
[doctor] nice okay so i believe we have you on lisinopril about twenty milligrams a day any side effects from that that you're noticing
[patient] not that i know of it's been a good medicine for me and i do n't have any trouble with it
[doctor] okay great alright and since you had this knee pain any numbing or tingling in your foot at all
[patient] no just the swelling and the pain
[doctor] okay and what have you taken for the pain
[patient] i i took some aleve twice a day some over the counter aleve twice a day
[doctor] okay and
[patient] putting a cold pack on it
[doctor] okay and has that helped at all
[patient] yeah that's helped a fair amount it's still pretty sore though
[doctor] okay alright well let's see have you ever had any surgeries before let me just think any surgeries i do n't see any in your in your record here
[patient] i had my tonsils out
[doctor] okay you had your tonsils out okay alright well let me go ahead i wan na do a just a quick physical exam i'm gon na go ahead and be calling out some of my clinical exam findings and i'll let you know what that means when i'm done okay so looking at your vital signs here in the office it does look like you're doing a really good job managing your blood pressure your blood pressure is up is about one twenty over seventy seven today here in the office and that's with you probably in a little bit of pain so that's good and on your neck exam i do n't appreciate any lymphadenopathy on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are clear to auscultation bilaterally on your musculoskeletal exam on your right knee i do appreciate some ecchymosis some edema there is an effusion present does it hurt when i press
[patient] yeah that's sore
[doctor] okay there is pain to palpation of the right medial knee there is i'm just gon na bend your knee in all sorts of directions here does that hurt
[patient] yeah do n't do that anymore
[doctor] alright the patient has decreased range of motion there is a negative varus and valgus test there is a negative lachman sign there is a palpable dorsalis pedis and posterior tibial pulse there is otherwise no lower extremity edema so what does that what does that mean kenneth so that so that means that you essentially i agree with you you had quite quite an injury to your knee and you do have a little bit of fluid in your knee there and just some inflammation which i think we need to talk about okay so i wan na go ahead and just talk a little bit about you know my assessment and my plan for you so for your first problem of your right knee pain i do believe you have what we call a a medial collateral ligament strain you know i wan na go ahead and just order an x-ray of your right knee just to make sure that we're not missing any broken bones which i do n't think we are but what's good about this particular injury is that people typically heal quite well from this and they typically do n't need surgery we can just go ahead and refer you to physical therapy to to strengthen those muscles around your knee so that you do n't have another injury and i wan na go ahead and just prescribe meloxicam fifteen milligrams once a day and that will help take down the swelling and help with some of the pain and you only have to take it once a day and it wo n't really cause any upset stomach or anything like that do you have any questions about that
[patient] yeah if i start that medicine today am i going to be able to ski tomorrow because we got a a big weekend plan
[doctor] i would say i would like you to rest your knee i i think that my concern is that if you go skiing again and you fall that you might injure your knee even more so i think you'll recover from this injury right now but i do n't want you to injure it anymore so i would rest it for a little while at least until we have the results of the x-ray and that type of thing okay for your second problem of your hypertension i wan na just go ahead and continue on lisinopril twenty milligrams a day i wan na just go ahead and order an a lipid panel just to make sure everything is okay from that standpoint and then i'm just looking through your health record and it looks like you're due for a tetanus shot so we'll go ahead and just give you a a tetanus shot for a from a health maintenance perspective any other questions
[patient] i think so sounds like a good plan to me
[doctor] okay sounds good alright so i'll see you later we'll get those ordered and i'll be in touch okay take care bye
[patient] thank you | CHIEF COMPLAINT
Right knee pain.
MEDICAL HISTORY
Patient reports history of hypertension.
SURGICAL HISTORY
Patient reports history of tonsillectomy.
SOCIAL HISTORY
Patient reports that he has a boat on Lake Martin. He is frequent water skier.
MEDICATIONS
Patient reports taking lisinopril 20 mg once a day.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right knee pain and swelling.
Neurological: Denies numbness or tingling in the right foot.
VITALS
Blood pressure: 120/77
PHYSICAL EXAM
Neck
- General Examination: Neck is supple without lymphadenopathy.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs.
Musculoskeletal
- Examination of the right knee: Ecchymosis noted. Effusion present. Pain to palpation medially. Decreased range of motion. Negative varus and valgus test. Negative Lachman sign. Palpable dorsalis pedis and posterior tibial pulse. There is otherwise no lower extremity edema.
Hematology/Lymphatic/Immunology
- Palpation: No enlarged lymph nodes.
ASSESSMENT AND PLAN
1. Right knee pain.
- Medical Reasoning: Based on the patient's symptoms and exam, I believe he has a medial collateral ligament strain.
- Patient Education and Counseling: We discussed the nature of this injury as well as the expected recovery outcome. He was advised surgery is typically not needed and that physical therapy will be beneficial for strengthening to prevent future injuries. He was also counseled to rest his knee until we at least receive his x-ray results in order to prevent further injury and to allow for a quicker recovery.
- Medical Treatment: X-ray of the right knee was ordered for further evaluation. Referral to physical therapy was provided for strengthening. A prescription for meloxicam 15 mg once a day for pain and swelling was also provided.
2. Hypertension.
- Medical Reasoning: The patient is doing well on his current medication regimen. He is monitoring his blood pressure at home and has not had any elevated readings.
- Medical Treatment: He will continue taking lisinopril 20 mg a day. Lipid panel was ordered today.
3. Health Maintenance.
- Patient Education and Counseling: I advised the patient that his records indicate that he is due for a tetanus vaccine.
- Medical Treatment: The patient will receive his tetanus vaccine in office today.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow-up for his x-ray results. |
D2N122 | aci | [doctor] hey kyle it's nice to see you today can you tell me a little bit about what brought you in
[patient] yeah i went to see my pcp for a cough which they diagnosed as bronchitis but then they did that chest x-ray to make sure i did n't have pneumonia and they found this lung nodule i went for a cat scan that confirmed it and they referred me here to you i'm really nervous document
[doctor] okay well first of all i'm i'm sorry that you're nervous and what we're gon na do is we're gon na partner together okay and i'm gon na be right by your side the whole time to hopefully make you a little less nervous and and recognize the fact that we're you're gon na have a big support team around you okay
[patient] okay
[doctor] so let's talk a little bit about how long you've had that cough before you went to see your doctor
[patient] i you know off and on i've had it for about three months i first noticed it when i was loading some pay i have horses and i i bought you know four hundred bills a day and when i spent a day loading it and then it's i just started coughing a lot more i think around that time and after that i i i just got a cold so that's what sent me to my pcp now i i i do exercise i i do a lot of biking and i typically do n't get sick and my cough has gone away
[doctor] okay that's good to hear you mentioned exercise and biking i love to bike myself i've got a track seventy one hundred hybrid have you been on the the new trails they opened it was the old the old rail the old rail road right away they've opened that up it's like sixty miles of trails
[patient] i love that that road i just i i do n't like riding on the road so i prefer to do those rails the trails type
[doctor] yeah
[patient] and it's just so phenomenal i do that a lot
[doctor] yeah i love riding over there way we will we will get you all fixed up we will have to go for a bike ride
[patient] absolutely i'd love it
[doctor] that'd be great so i see here on your medical history that you also have a history of rheumatoid arthritis is that under control at this time and and and what do you do to to take care of your ra
[patient] yeah it's it's it's fair you know arthritis never really goes away but i take methotrexate
[doctor] okay
[patient] i think it's seven and a half milligrams every week and as long as i'm keeping active my joints feel okay and if i do have any problems it's it's mostly with my hands but i have n't had any recent flares so i'm okay right now
[doctor] okay that's good i also see here that you marked down that you were a previous smoker and and when when did you when did you stop smoking
[patient] i stopped smoking probably about seven years ago
[doctor] okay
[patient] and i was young and should have stopped the way before that my kids were on me all the time but you know i i got a new start and finally was able to stop and i felt better after stopping
[doctor] okay that's good and i'm glad to hear that you were able to to to stop and and stay tobacco free that that's great to hear do you have any pain or any shortness of breath or anything like that
[patient] no not at all
[doctor] okay and i would like to talk about your familial history here for just a second do you have any family history of lung cancer or any other type of malignancies
[patient] no lung cancer my mom did have breast cancer but she is doing well now
[doctor] okay alright and then things like lung infections or pneumonia do you have any previous history of that
[patient] no no not not anything that i'm aware of
[doctor] okay if it's okay with you i'm gon na do a quick physical exam your vital signs look good today blood pressure of one twenty four over seventy six heart rate of seventy respiration rate of sixteen o2 sat on room air of ninety eight percent and you are afebrile so you do n't have a fever today i'm gon na take a quick listen to your lungs here your lungs are clear and equal bilateral when i listen to them or when i auscultate your lungs now listening to your heart regular rate and rhythm no clicks rubs or murmurs and i do n't appreciate any extra beats doing a quick extremity exam your skin is pink warm and dry i do n't appreciate any edema to your lower extremities it looks like you do have a little bit of swelling to to your knuckles there on your third digit on each hand which can be normal for somebody who has ra however pulses are intact in all extremities and capillary refill is brisk so a quick review of your results now you had a chest ct before you came in to see me and the results of that chest ct do show a solitary two centimeter nodule in the lateral aspect of the right upper lobe now it appears the nodule is smooth in appearance and no evidence of any type of emphysematous disease is present which is good now for my assessment and plan for you so you do have an incidentally found right upper lobe lung nodule i'm going to order some pft which is pulmonary function test i just wan na get a check and and a baseline for your lung function i'm also going to schedule a pet ct this is gon na help to determine if that nodule is metabolically active meaning if it lights up it it can suggest that it's cancer or inflammatory i'm going to go ahead and suggest that we do remove this during or via video assisted thoracoscopy which means it's just gon na be three small incisions made on the side of your right chest i'm gon na go in with a camera and a scope and we'll remove that along with a very small portion of your lung you're gon na be under general anesthesia and it'll take about an hour and a half or so post procedure you're gon na be admitted and you will have a chest tube in until the following day and i'm gon na go ahead and take that out then at bedside most likely you're gon na be in the hospital for one night and go home the next day it could be a benign nodule but because your smoking history i really do think it's gon na be best that you have that removed now for your secondary concern of your rheumatoid arthritis i want you to continue to follow up with your rheumatologist and continue your medication therapy as has been previously outlined for you now do you have any questions comments or concerns before before we get the paperwork signed to start the the treatment process
[patient] no i do n't think so i think i'll be okay i'm scared
[doctor] i i know you're scared but we'll be right here with you the whole way
[patient] okay
[doctor] alright we'll get some paperwork and i'll see you again in a few minutes
[patient] okay thank you | CHIEF COMPLAINT
Cough.
MEDICAL HISTORY
Patient reports a history of rheumatoid arthritis. He denies any previous history of lung infections or pneumonia.
SOCIAL HISTORY
Patient reports he stopped smoking tobacco 7 years ago and has felt better since doing so. He notes that he enjoys biking.
FAMILY HISTORY
Patient reports his mother has a history of breast cancer, but is doing well. He denies any family history of lung cancer.
MEDICATIONS
Patient reports taking methotrexate 7.5 mg every week.
REVIEW OF SYSTEMS
Respiratory: Denies cough or shortness of breath.
VITALS
Blood Pressure: 124/76 mmHg.
Heart Rate: 70 beats per minute.
Respiratory Rate: 16 breaths per minute.
Oxygen Saturation: 98% on room air.
Body Temperature: Afebrile.
PHYSICAL EXAM
Respiratory
- Auscultation of Lungs: Clear and equal bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No clicks, rubs, or murmurs. Pulses are intact in all extremities.
Musculoskeletal
- Examination: No lower extremity edema. Mild swelling to the 3rd digit knuckles on the bilateral hands, consistent with RA.
Integumentary
- Examination: Skin is pink, warm, and dry. Capillary refill is brisk.
RESULTS
CT scan of chest, obtained at an outside facility, is reviewed today and demonstrates a solitary 2 cm nodule in the lateral aspect of the right upper lobe. It appears the nodule is smooth in appearance. No evidence of any type of emphysematous disease is present.
ASSESSMENT AND PLAN
1. Right upper lobe lung nodule.
- Medical Reasoning: The patient has incidentally found right upper lobe lung nodule visible on his chest CT. It could be a benign nodule, but because of his smoking history, I think it is best that he has it surgically removed.
- Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. Surgery will require general anesthesia and will take approximately 1.5 hours. I explained to the patient that his procedure will consist of 3 small incisions being made on the side of his right chest. I will then insert a camera and scope to assist in removing the nodule along with a very small portion of his lung. He was advised that he will be admitted for most likely an overnight stay. He will have a chest tube in until the following day when I remove it at his bedside. All questions were answered.
- Medical Treatment: Pulmonary function test ordered today to obtain patient's baseline. PET CT will also be scheduled to determine if the nodule is metabolically active, which can suggest if it is cancerous or inflammatory. Nodule will be removed via video assisted thoracoscopy.
2. Rheumatoid arthritis.
- Medical Reasoning: Stable.
- Patient Education and Counseling: I encouraged the patient to continue to follow up with his rheumatologist.
- Medical Treatment: Continue medication therapy and routine follow up with rheumatologist as previously outlined.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N123 | aci | [doctor] so tyler is a 56 -year-old male who presents today complaining of difficulty swallowing and has a past medical history of diabetes and high blood pressure so tyler tell me what's going on with your swallowing problem
[patient] well it's just been something that i have noticed over the last you know four to five weeks it seems like something is always stuck in my throat and you know just i kinda go about my day and it kinda bothers me you know a little bit sometimes a little painful and when i try to eat it just seems like i have to i do n't know when it's something solid i kinda have to wash it down on occasion i i've never really fully choked but i have to admit that i've thought about potentially choking
[doctor] okay and is it seem to be stuck in your throat or does it seem to go in your lungs area or are you coughing with this at all or just mostly when you're swallowing
[patient] no coughing just kinda when i swallow it's all okay with liquids but when i kinda swallow you know like a bite of a sandwich sometimes it just feels like like i just need a little help pushing it down
[doctor] okay and is it more kind of a like heart like steaks or heart like larger solid like things that are that you have to chew more or is it even soft stuff like you know to eat yogurt and stuff like that
[patient] i'm not a hundred percent sure but i think it's probably more with solids
[doctor] okay how about have you noticed anything different with when you're swallowing cold or or or hot liquids is there is there a temperature change any modification to that
[patient] it's really just about solids
[doctor] okay alright so have you noticed any blood in any place or blood in your stools or are you vomiting anything up at all
[patient] no
[doctor] okay that so no vomiting blood no coughing up blood or anything like that any weight loss or changes in your weight at all
[patient] not that i want
[doctor] okay yeah i mean i think we all like to lose a little bit of weight but yeah it's a it says it's a struggle so no no chest pain or shortness of breath with this
[patient] no
[doctor] okay so i i'm gon na you know we'll talk about that in a second i'll look at your throat as well and see what we need to do but it sounds like we may have to send you to a specialist to take a look at that and see if there is something causing this how about how are you doing with your diabetes by the way since i have n't seen you in a while i know we have you on metformin five hundred milligrams twice a day we checked your hemoglobin a1c last time was seven . four we talked about improving your diet and exercise how are things going
[patient] i think they're going great i mean i'm taking my meds i'm sticking to them and i feel pretty good otherwise
[doctor] okay are you checking your blood sugars in the morning or are you checking those at all
[patient] yeah i do i mean once in a while i i'm in a hurry and i skip it but i have to say i probably do so about eighty percent of the time
[doctor] and how are the numbers looking
[patient] they're looking you know okay they are all within you know the range that we are targeting
[doctor] okay alright and any any no nausea vomiting or diarrhea or any other side effects from the metformin or anything like that
[patient] no
[doctor] okay good so i think we should probably repeat your hemoglobin a1c it sounds like you've you know you've improved your diet and it sounds like you've you're following the regimen so maybe the numbers will be better this time and we do n't have to change your medication so that will be awesome how are you doing with your blood pressure i know we have you on norvasc we asked that you check it like you know once a week or more than that if you have time blood pressure looks good today in the office it's about one fifty i'm sorry one twenty over fifty right now so no nothing here in the office how are things at home
[patient] i get there now every once in a while you know the lower numbers a little bit you know higher but it's not you know usually it's either close or or on on range
[doctor] okay alright good so let me examine you now so tyler i'm examining you now i'm gon na just verbalize some of my findings your neck is fine i do n't see any swelling in your neck your thyroid feels normal i do n't feel any masses in your neck there's no lymph nodes i'm looking at your throat and that looks okay there is no masses or any swelling that i can see there is no redness yeah there is no carotid bruit your lung exam is clear your heart exam is normal no murmurs on your belly exam you have some epigastric tenderness right here in the right here where i'm pressing but i do n't feel any masses or any significant swelling back there no normal back exam your extremity exam looks normal your neurological exam's fine so for this difficulty swallowing i'm concerned that you may have a narrowing in your throat that's causing this and sometimes it can be from a stricture where some narrowing of the esophagus and sometimes i need to go in and dilate that so i'm gon na go ahead and send you give you a referral for gastroenterology and have them do a scope and take a look down there i'm gon na recommend we put you on some prilosec sometimes also reflux medicine can if you have reflux sometimes that can also exacerbate this sometimes so i'm gon na put you on some prilosec twenty milligrams once a day again i'm gon na recommend that you chew your foods frequently and make sure you have a you know especially if you're eating something hard like steak or meat chew them really well so they do n't get tend to get stuck some people have sometimes things get stuck and they do n't go down and if that happens as an emergency you do have to go to the emergency department but seems like you know things are going down they just seem to sometimes slow down or get stuck temporarily so why do n't i get you a referral for gi we will start you on the prilosec and then we will have you you know if you you know if you have any other symptoms or worsenings give my office a call we will get you in or get you referred to the er if needed any questions about that
[patient] no that sounds great
[doctor] okay and for the diabetes i'm gon na order another hemoglobin a1c i'm gon na order some more blood work today we'll check a kidney function and i notice that you have not had an eye referral so i'm gon na also give you an eye referral to ophthalmology to check your eyes for your diabetic for your for any retinopathy continue the metformin i'll have you come back in about a month and that way we'll have the results back for the blood test if we need to make any adjustments we can but i i wan na see you back in about a month and i think that's it for that any questions about that
[patient] no
[doctor] okay and the high blood pressure i think you're doing great continue with the norvasc if you have any issues certainly call me but otherwise there is really nothing else to add for that did we forget anything or do you need refills for anything
[patient] you know i think i'm low on the norvasc so if you could send something to my pharmacy that would be great
[doctor] okay sure i'll get you a refill for norvasc we'll get that sent over to the pharmacy okay
[patient] thank you
[doctor] alright thanks good seeing you thanks for coming in to them | SUBJECTIVE
Difficulty swallowing. Tyler Green is a 56-year-old male who presents today complaining of difficulty swallowing.
The patient noticed the difficulty swallowing approximately 4 to 5 weeks ago. He describes it as something stuck in his throat. He states that it bothers him a little bit throughout the day as sometimes it becomes painful. The patient states that occasionally when he tries to eat something relatively solid it seems to get stuck and he will have to wash it down with a drink. He states that he has never fully choked before, but has recently thought about potentially choking. He denies having to cough. Denies having this issue with liquids, hot or cold. Denies hematochezia, vomiting blood, coughing up blood, any weight changes, chest pain, or shortness of breath.
Regarding his diabetes, the patient states he is doing well. He states that he checks his blood sugars most of the time, but sometimes he is in a hurry and will forget. However, he does note that when he checks his blood sugar, they are within range. He is compliant with his metformin 500 mg twice a day. He denies any side effects of the metformin such as nausea, vomiting, or diarrhea. His last hemoglobin A1c was 7.4.
In regards to his blood pressure, the patient states that he is doing okay. He notes that occasionally he will have a lower blood pressure and then other days it will be elevated. However, he states they usually close in range. He is still taking Norvasc.
MEDICAL HISTORY
Patient reports a history of diabetes and hypertension.
MEDICATIONS
Patient reports that he take metformin 500 mg twice a day and Norvasc.
REVIEW OF SYSTEMS
Constitutional: Denies weight changes.
HENT: Reports dysphagia.
Cardiovascular: Denies chest pain.
Respiratory: Denies cough, shortness of breath, or hemoptysis.
Gastrointestinal: Denies hematochezia, hematemesis, vomiting, nausea, or diarrhea.
VITALS
Blood pressure in office today is 120/50.
PHYSICAL EXAM
Neck
- General Examination: Neck is supple without thyromegaly or lymphadenopathy. No swelling. No masses noted. No carotid bruits. No redness noted.
Respiratory
- Assessment of Respiratory Effort: Normal respiratory effort.
- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.
Gastrointestinal
- Examination of Abdomen: No masses or swelling. Epigastric tenderness noted.
Musculoskeletal
- Normal back examination.
- Normal capillary refill and perfusion.
Hematology/Lymphatic/Immunology
- Palpation: No enlarged lymph nodes.
ASSESSMENT AND PLAN
1. Difficulty swallowing.
- Medical Reasoning: The patient describes difficulty swallowing when he eats solid foods.
- Patient Education and Counseling: We discussed that I am concerned he has a narrowing in his throat that is causing this. I advised the patient the gastroenterology will do a scope. I recommended Prilosec as he might be experiencing reflux. We discussed that he should eat his food slowly and chew his food frequently. I advised the patient to call our office if his symptoms worsen.
- Medical Treatment: I referred the patient to gastroenterology. I prescribed Prilosec 20 mg once a day.
2. Diabetes.
- Medical Reasoning: This seems well-controlled.
- Patient Education and Counseling: The patient will continue with his metformin as he seems to be doing well. I advised the patient to follow up in 1 month for results and any adjustments that may be needed.
- Medical Treatment: Continue metformin 500 mg twice a day. I ordered another hemoglobin A1c, as well as a kidney function test. I referred the patient to ophthalmology for retinopathy.
3. High blood pressure.
- Medical Reasoning: This seems well-controlled.
- Patient Education and Counseling: I advised the patient to continue his current medication, Norvasc.
- Medical Treatment: I refilled the Norvasc.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow-up in 1 month for his diabetic lab results and any modifications needed.
|
D2N124 | aci | [doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened
[patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april and we were at the courts plan and i went up for a shot and he's far more aggressive than with me than he is with you know his peers i guess he could say and so he he found me while i was going for a lap and then when i came down i kind of landed awkwardly and i kind of like rolled and twisted my my ankle so now it's it's hurting a bit like kind of on the outside you can you can even see it's it's bruised up and a bit swollen
[doctor] yeah
[patient] and yeah i've been having trouble walking and it just does n't feel solid really stable which is a problem i i recently got back into working out and i had been in a really good rhythm going to the gym
[doctor] okay
[patient] and i do n't want to disrupt that moments on because it took a lot for me to get back to a good place so
[doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way
[patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys
[doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad
[patient] yeah yes
[doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too
[patient] yeah a little bit
[doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all
[patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid
[doctor] sure so it does n't quite feel stable
[patient] yeah
[doctor] okay okay i gotcha so i know you had an x-ray as you came in today and so i'm just looking at this x-ray here i'll show you on the screen right here i can turn my monitor towards you this is an ap lateral oblique and this is your right ankle so what we're looking at is a displaced lateral malleolus at the weber c level there's no evidence of medial or posterior malleolar fractures but this is a fracture on the lateral side of your ankle now based on the position it's a bit unstable that's why you're feeling some of that that instability when you're walking so for your diagnosis what i'm gon na put down is a lateral malleolar fracture and what i would recommend for that since it is in the location that it is is you're probably unfortunately gon na need surgery we're gon na wan na get that healed what that includes is putting some plate and some screws in and you're gon na be out for a little bit so i know you've been trying to work out and and you wan na get back on the court but but you may have to have to sit out for a little bit we'll get you some crutches
[patient] how long it's a little bit because i'm also i i forgot to say i'm also i did volunteer to coach
[doctor] great
[patient] starting in april so
[doctor] alright well
[patient] how long
[doctor] yeah you you're probably gon na be out for about three months but continue the coaching go ahead and and let's get you back out there we'll get you some crutches and and hopefully you can kinda you know get back on the court start coaching and then within that three months we'll we'll get you back out doing some exercise again
[patient] okay
[doctor] alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly
[patient] yeah i i work from home so that that should n't be a problem it's just everything else i do n't know who is gon na walk my dogs and and do all this stuff that's rest of my family refuses to walk my dog so we'll figure it out
[doctor] yeah i i'm a dog walker as well so alright sorry for the bad news but let's get you healed up so that we can get you back out doing everything you need to do
[patient] alright thank you doctor
[doctor] alright thanks | CHIEF COMPLAINT
Right ankle injury.
HISTORY OF PRESENT ILLNESS
Jerry Cook is a 45-year-old male who presents today with a right ankle injury.
The patient sustained an injury to the right ankle while playing basketball with his son. He reports he landed awkwardly and twisted his right ankle after jumping to make a layup. His pain is primarily located along the lateral aspect of the right ankle. He notes bruising and swelling. The patient is able to weight-bear while standing. He experiences pain and feelings of instability within the ankle while ambulating and is concerned for further injury.
SOCIAL HISTORY
The patient works from home and plans to coach his son’s basketball team in 04/2022. He enjoys working out and reports he recently resumed engaging in a consistent gym routine.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right ankle pain and instability.
Skin: Reports right ankle bruising and swelling.
PHYSICAL EXAM
CV: Brisk capillary refill.
SKIN: No epidermolysis. Intact.
MSK: Examination of the right ankle: Exquisite tenderness laterally. Mild tenderness over the medial deltoid region. Swelling on the lateral side of the ankle. No horrible malalignment.
RESULTS
X-rays, including AP, lateral, and oblique views of the right ankle, were obtained in the office and reviewed today. These demonstrate a displaced lateral malleolus at the Weber C level. There is no evidence of medial or posterior malleolar fractures.
ASSESSMENT
Right lateral malleolar fracture.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding treatment options. Recommendation was made for an open reduction internal fixation of the right ankle. We discussed the risks and benefits of the procedure as well as the postoperative recovery period following surgery. I advised that it will be 3 months before he can resume his exercise routine. In the meantime, I will prescribe meloxicam to reduce swelling. I recommended he ice and elevate the ankle as well. He will be given crutches to assist with ambulation.
The patient understands and agrees with the recommended medical treatment plan. |
D2N125 | aci | [patient] miss edwards is here for evaluation of facial pain this is a 54 -year-old male
[doctor] how're you doing doctor cruz nice to see you today
[patient] good to see you mister edwards i'm doctor
[doctor] tell me what's been going on yeah so i've got this stabbing shooting pain i've had for a while you know and it it especially right here in my right face right in that cheek bone area it's sometimes it gets super hot i've had it for i think a couple of months now and i went to my family doctor and they said i should come see you
[patient] okay great i would like to ask you a little bit more about that
[doctor] had in your face do you remember how long that you had it probably for about two or three months just just came on slowly i started noticing it but now it's i have episodes where just shooting stabbing kind of a pain in my right cheek bone right face area
[patient] mm-hmm do you have any sensory loss meaning like numbness or tingling in that part of your face
[doctor] not that i've noticed no okay do you have any symptoms like this anywhere else on your face including the other side of your face
[patient] no it's just on the right side mostly not on the left side just on the right side of my face
[doctor] have you noticed any weakness on that side of the face like when you smile or while you're doing other things any weakness there not really i mean i've i've i've tried to you know when i smile my smile seems equal on both sides my eyes i do n't have any weakness there my vision seems to be unchanged but just this stabbing severe pain it's just like excruciating pain that i get sometimes does it happen on its own or there are certain things that trigger it
[patient] sometimes if i'm if certain temperatures seem to trigger it sometimes or if it's super where it's cold i get a trigger sometimes
[doctor] sometimes certain kind of sensory outside of the wind sometimes that seems to trigger it but that's about it
[patient] okay and anything that you've done to to that helps for a little bit when you
[doctor] pain excess
[patient] you know i've tried ibuprofen and motrin that had really has n't helped it just comes on suddenly and then it's kinda stabbing excruciating pain i've tried rubbing some you know some tiger balm on it that did n't work
[doctor] but that's you know so i i went to my family doctor and he said you know i really need to see a neurosurgeon
[patient] got it how long do these episodes last these pain
[doctor] you know it can last for anywhere from a few minutes to sometimes about an hour but generally generally a few minutes
[patient] any history of something like multiple sclerosis or any brain tumors that you know
[doctor] no nothing like that alright any other kinda headache symptoms that have anything like you had migraines or anything related to the headaches i mean i get occasional headaches but not really i do n't have a history of migraines but i occasionally get headaches like everybody else i take some tylenol that usually goes away but this is different
[patient] how severe is the pain on a scale of one to ten
[doctor] when it comes on it's like a ten it's like somebody is stabbing you with an ice pick and but usually you know after a few minutes usually it goes away but sometimes it can last up to an hour great so mister i would like to do a physical exam if that's okay with you
[patient] sure
[doctor] i would like you to follow my finger here and i see that you're following my finger in in both directions can you show me your teeth
[patient] that looks nice and symmetric i'm gon na rub my fingers next to your ear can you hear that
[doctor] yep
[patient] you can hear it on the other side as well
[doctor] yep
[patient] okay
[doctor] i'm gon na take this cotton tape and run it along the side of your face can you feel that okay
[patient] yeah it's a little bit numb on my right side not so much on my left side
[doctor] okay alright i'm gon na use this little needle here and i'm gon na poke here and i wan na see if you feel like it's being sharp or dull on that part of your face does that feel different or normal
[patient] it feels a little bit dull on my left on my right side my left side it feels sharp
[doctor] alright good well i had a chance to look at your mri
[patient] okay
[doctor] and i looked at your mri and it appears to have small blood vessel that is abutting and perhaps even pinching the trigeminal nerve the trigeminal nerve is nerve that comes from the brainstem that goes out to the face and provides the sensory inflammation from the face and you may have a condition called trigeminal neuralgia
[patient] okay
[doctor] where the nerve compression causes this kind of shooting electrical pain in the face how do we treat it
[patient] well the first line would be to try some medications usually we start with medications that are called gabapentin
[doctor] or tegretol these are medications that really help reduce the excitability of the nerve
[patient] okay
[doctor] most people can get the pain control with that but there are some people where the medications are n't gon na be enough and in that situation we would consider surgery i would n't i would n't recommend that now we usually try the medications first
[patient] for considering a surgery to decompress the nerve the root cause of the problem is the compression of the blood vessel against the nerve
[doctor] okay so we should be tried which one would you recommend the tegretol or yeah i think we could start with the tegretol to start with i just want to make sure that you understand some of the potential side effects that you can have with this
[patient] sure
[doctor] it's always a little bit of trial and error to figure out what the right dosing that would work for you but some common side effects can include you know memory loss tingling imbalance some people can actually have like dermatologic
[patient] skin reaction to this medication and particularly people who have eustachian descent so that we may do some genetic testing just to make sure that it will be safe for you
[doctor] okay sounds good let's do it
[patient] okay so i will prescribe that for you and then we will see how that goes and if your pain continues we can talk about different surgical options to treat the pain
[doctor] yeah i think i would like to try the tegretol first and if that does n't work then i can come back and so once should i come back and just to kinda check back with you and see if you know if it's had enough time for a fact or not
[patient] i think one month would be a great time to follow up
[doctor] okay sounds good so if you want to send that prescription over to my pharmacy that would be fine and then why do n't i come back in about a month and we'll go from there
[patient] great i'll see you then
[doctor] alright | CHIEF COMPLAINT
Right-sided facial pain.
REVIEW OF SYSTEMS
Eyes: Denies vision changes or weakness in right eye.
HENT: Reports right sided facial pain. Denies left sided facial pain. Neurological: Reports headaches. Denies sensory loss, numbness, or tingling in the right cheek. Denies right sided facial weakness.
PHYSICAL EXAM
Neurological
- Orientation: Light touch testing of the right side of the face reveals numbness when compared to the contralateral side. Pinprick testing is sharp on the left side of the face; dull on the right side of the face.
Ears, Nose, Mouth, and Throat
Bilateral finger rub test is negative.
- Examination of Mouth: Teeth are symmetric.
RESULTS
MRI of the head is reviewed today. This demonstrates a small blood vessel that is abutting, and perhaps even pinching, the right trigeminal nerve.
ASSESSMENT AND PLAN
1. Trigeminal neuralgia.
- Medical Reasoning: The patient has been experiencing facial pain for 2 to 3 months. A recent MRI revealed a small blood vessel abutting, or perhaps even pinching, the right trigeminal nerve. The root cause of his facial pain is the compression of the blood vessel against this nerve.
- Patient Education and Counseling: The patient and I discussed treatment options including medicating with gabapentin or Tegretol. I explained the common side effects associated with these medications can include memory loss, tingling, and imbalance. We discussed the need for genetic testing due to the possible side effect of dermatologic reactions in people of East Asian descent. We also briefly discussed surgical treatment to decompress the nerve, but this is not recommended at this time.
- Medical Treatment: A prescription for Tegretol will be sent to the patient’s pharmacy.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up with me in 1 month. If at that time his facial pain persists, we may further discuss surgical options. |
D2N126 | aci | [doctor] hi michelle what's been going on the medical assistant told me that you injured your knee
[patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since
[doctor] okay and were you able to ski down the hill or did you have to be taken down by the ski patrol
[patient] i had to be taken down by the ski patrol i was unable to bear weight
[doctor] okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside
[patient] it hurts on the outside but it also feels like it wo n't hold my weight
[doctor] okay so it feels like it's gon na buckle
[patient] hmmm yes
[doctor] okay alright and are you able to bend it
[patient] i was immediately after the injury but not really now
[doctor] okay and how about straightening it are you able to straighten it at all
[patient] somewhat but it really hurts when i try to straighten all the way
[doctor] okay alright now do you have any numbing or tingling in your toes
[patient] no
[doctor] okay and can you feel your toes okay
[patient] i think so
[doctor] okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do
[patient] i chase my two four -year-old
[doctor] okay do you have twins
[patient] i do
[doctor] nice that's great
[patient] yeah
[doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or
[patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids
[doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy
[patient] yes
[doctor] okay and no high blood pressure diabetes anything like that
[patient] mm-hmm
[doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again
[patient] my right knee
[doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press
[patient] yes
[doctor] okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain
[patient] ibuprofen
[doctor] is that helping
[patient] somewhat yes
[doctor] okay alright do you want something stronger
[patient] no i'm okay
[doctor] alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured
[patient] hmmm no i not i i would like to get back to the running but currently not that active
[doctor] okay alright alright do you have any questions about anything
[patient] i think you've explained it well
[doctor] okay alright so i'll see you again soon okay
[patient] okay thank you
[doctor] alright take care bye | CHIEF COMPLAINT
Right knee injury
HISTORY OF PRESENT ILLNESS
Michelle King is a pleasant 44-year-old male who presents to the clinic today for the evaluation of a right knee injury. Her injury was sustained while skiing in Vermont last weekend after she caught her ski when coming off of the lift and fell. She reports a pop in her knee at the time of injury and has been experiencing pain since that time. Due to her fall she was unable to weight bear and had to be taken down by the ski patrol. She locates her pain to the lateral aspect of her knee and also describes the feeling of instability as well as buckling. At this time she is experiencing difficulty with knee flexion; however, she states this was not a problem immediately after the injury. Full knee extension is also quite painful for her. The patient denies any numbness or tingling in her toes. She is currently utilizing crutches for ambulation which were provided to her by the ski patrol. In terms of pain control, she is taking ibuprofen which is providing some relief.
MEDICAL HISTORY
Patient reports she is otherwise healthy and denies a history of high blood pressure or diabetes.
SOCIAL HISTORY
Patient reports she is very active with skiing and taking care of her 4-year-old twins. She mentions that she would like to get back into running at some point. She states that her husband is home with her, but he also works a job where he has gone quite a bit.
MEDICATIONS
Patient reports she is taking ibuprofen.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right knee pain and limited range of motion.
Neurological: Denies numbness or tingling in toes.
PHYSICAL EXAM
GAIT: The patient is ambulating with crutches.
CV: Regular rate and rhythm. No murmur.
RESPIRATORY: Lungs are clear to auscultation.
MSK: Examination of the right knee: Edema and effusion noted. Pain with palpation of the lateral knee. Decreased flexion and extension. Positive Lachman's. Palpable dorsalis pedis and posterior tibial pulse. No ankle edema.
RESULTS
4 views of the right knee were taken today. These reveal no bony abnormalities.
ASSESSMENT
Right knee pain, possible ACL tear.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate for a possible ACL tear. In the meantime, I have advised her to continue taking ibuprofen 600 to 800 mg every 8 hours as needed for pain. She will also be placed into a brace for increased knee support.
INSTRUCTIONS
The patient will follow up with me once the MRI results are available for review and further discussion. |
D2N127 | aci | [doctor] hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened
[patient] yeah i was in a car crash
[doctor] wow okay when was that
[patient] well which car crash
[doctor] okay so multiple car crashes alright so let's see if we can how many let's start
[patient] my therapist said well my well actually my mother said i should go see the therapist and the therapist said i should see the lawyer but my neck's hurting
[doctor] okay so i'm glad that you know you're getting some advice and so let's let's talk about this neck pain how many car crashes have we had recently
[patient] well the ones that are my fault or all of them
[doctor] all of them
[patient] i was fine after the second crash although i was in therapy for a few months and then after the third crash i had surgery but i was fine until this crash
[doctor] okay the most recent crash when was that
[patient] that's when i was coming home from the pain clinic because my neck hurt and my back hurt but that was in february
[doctor] okay alright so we had a car crash in february
[patient] what year it was which february it was
[doctor] okay so let's let's try with this one see what happens hopefully you remember i need you to start writing down these car crashes that this is becoming a thing but you know it's okay so let's let's say maybe you had a
[patient] you're not judging me are you
[doctor] no there's no judgment here whatsoever i want to make sure that i'm giving you the best advise possible and in order to do that i need the most information that you can provide me makes sense
[patient] yes
[doctor] alright so we're gon na say hope maybe that you had a car crash and we can verify this in february of this year and you've been experiencing some neck pain since then right
[patient] yes
[doctor] okay alright on a scale of one to ten what ten is your arm is being cut off by a chainsaw severe how bad is your pain
[patient] twelve
[doctor] okay terrible pain now i know you mentioned you had previous car crashes and you've been to therapy has anyone prescribed you any medication it's you said you went to a pain clinic yes
[patient] well they had prescribed it recently i was i was on fentanyl
[doctor] oh
[patient] i have n't gotten a prescription for several weeks
[doctor] okay alright and so we will be able to check on that when you take your medication so before you take your medication rather like are you able to move like are you experiencing any stiffness
[patient] yes but it hurts
[doctor] okay it hurts what kind of pain is it sharp is it dull is it throbbing
[patient] it's the sharp incapacitating pain i ca n't work
[doctor] wow okay are you having any headaches
[patient] of course
[doctor] any dizziness
[patient] just sometimes
[doctor] any visual disturbances is it hard to like are you
[patient] not recently no
[doctor] okay alright any numbness
[patient] yes
[doctor] where
[patient] my left arm and my right leg
[doctor] okay any spasms
[patient] of course
[doctor] okay where
[patient] my body hurts i told you my neck hurts
[doctor] okay so i no i'm absolutely i wan na make sure that we are gon na give you the medication that works like the best for you so i'm sorry if these questions seem like frustrating i would just wan na make sure that i understand what the problem is so
[patient] i saw pamela and doctor collins's office she's much nicer than you know
[doctor] i mean okay so you know what like maybe maybe pamela would be better like we could maybe talk talk about a referral if that would make you more comfortable
[patient] my lawyer told me to come here
[doctor] then you're stuck with me okay i'm so sorry but here it's we're gon na try and make it as good as possible alright so last thing i do wan na do my physical exam alright and i need you to let me know as as much as you as much as you can verbalize right so when i push here in the middle of your neck on top of the bone does it hurt
[patient] yes yes
[doctor] okay alright sorry what about on the side does that hurt
[patient] yes
[doctor] okay so pain on palpation both on the bony process and on the muscle can you move your neck from side to side can you move your neck can you swive it side to side no no alright so i'm i'm seeing i'm seeing some range of movement moderate range of movement that's fine okay i so when can you bend your neck forward that that's your whole body just just the neck are you capable of bending up
[patient] really hurts it really hurts
[doctor] okay it really hurts to bend forward and backwards okay alright so i'm just gon na make a little note here i do n't i do n't see any bruising i'm not noticing any swelling there is i i do n't see any laceration what
[patient] just sometimes it bruises
[doctor] okay sometimes alright that's fine i i just i'm not seeing one here today so that's okay alright so with that being said i do wan na ask have you been experiencing any fatigue are you tired
[patient] well since the accident yes
[doctor] okay alright just making sure okay so this is what this is my assessment and plan this is what we are gon na do i want to be able to like we had you do an x-ray before you came in here and looking at it i'm not noticing any fracture that's a really good sign considering how many car accidents we've been in lately
[patient] it hurts it hurts
[doctor] absolutely no i we're gon na address the pain so for my first so looking at your imaging results though i'm not seeing a fracture that's a great sign so for your first diagnosis i'm gon na say that you have what is called a neck sprain that
[patient] thinking are are you saying i'm thinking
[doctor] no not by any means i am saying
[patient] pain i have a lot of pain
[doctor] yes and your pain can be explained by multiple things but thankfully it's not a broken neck is that okay
[patient] yes
[doctor] alright so what we are gon na do when we are gon na like try and treat this as conservatively as possible
[patient] said it might be broken
[doctor] what
[patient] pamela said it might be broken
[doctor] if pamela said it's broken then you know what this is what we're gon na do we're gon na order something called a ct that's gon na give us even nope you know what let's upgrade to an mri it's gon na give us the most thorough image of everything that's going on the heart and the soft tissues is that gon na is that so that way we can really get a good image of what's happening inside right
[patient] okay because what the lawyer said i needed was an mri
[doctor] not a problem we're we're gon na make your lawyer happy next step we are going to try working like from the outside in so i do need you to work on getting like you're you're saying you've seen some bruising and some swelling yourself so i want you to put ice on that whenever you're experiencing that in the moment when you wake up i want you to do your best to just like i'm gon na give you some exercises on the sheet and i want you to roll through these exercises every morning right to just get some like movement and like free frenosive movement back into your neck i also wan na put you on a couple medications now i know that you said you were on fentanyl before that's a bit extreme and i i want i i i wan na like monitor this a little more conservatively so what we're gon na start with is something called robaxin
[patient] hurts a lot if i do n't get more fentanyl
[doctor] you know we can refer you to pain medicine if it really is getting that complicated but for this current period we're gon na put you on some robaxin it's gon na be fifteen hundred milligrams and you're gon na take that six to eight hours every six to eight hours and that really should help kinda relax the muscles in the area take off some of that tension and really help with that pain if you're noticing that the robaxin still is n't helping maybe then we can start we can like start using like a heat pad or maybe some icyhot the biofreeze is a really good one to kinda help with that and then we will refer you to physical therapy i think with the mri we can start evaluating maybe some additional steps so rather than you having to like take that fentanyl because i do n't want you to be in danger right like people i do n't want you to get rubbed so what we could explore are local injections right and we can refer you to pain medication and see about like locally injecting the area and that should be able to help you out hopefully with this
[patient] i ca n't go to work like this
[doctor] okay so if it's if it's that bad let's wait for the mri result we're gon na give you off for work because you know you ca n't move and we'll see what the mri says about what whether or not we can get you like true local injections in the moment is that alright for now
[patient] yeah
[doctor] okay okay any other questions
[patient] not right now
[doctor] alright | CHIEF COMPLAINT
Neck pain.
HISTORY OF PRESENT ILLNESS
Brandon Green is a pleasant 46-year-old male who presents to the clinic today for the evaluation of neck pain. His pain began when he was involved in a motor vehicle accident in 02/2022 when he was on his way home from a pain clinic. The patient notes that he has been in 4 motor vehicle accidents; however, he notes that he was fine after the first two accidents, but the third motor vehicle accident is when his neck and back pain began. He states that he was in therapy following the second accident and had surgery after his third accident. The patient was seen at a pain clinic secondary to neck and back pain. He was prescribed fentanyl; however, he has not received a prescription for several weeks. Today, he reports that his pain is a 12 out of 10. He describes his pain as sharp and incapacitating with stiffness and pain. The patient also reports headaches, occasional dizziness. He denies any recent visual disturbances. He also reports numbness in his left arm and right leg. The patient also reports spasms throughout his body. He states that he has been experiencing fatigue since the accident. He notes that he is unable to work with this much pain.
REVIEW OF SYSTEMS
Constitutional: Reports fatigue.
Eyes: Denies any recent visual disturbances.
Musculoskeletal: Reports neck and back pain, and occasional swelling and bruising of the neck.
Neurological: Reports headaches, dizziness, spasms, and numbness.
PHYSICAL EXAM
SKIN: No lacerations.
MSK: Examination of the cervical spine: Pain on palpation on the bony process and muscle. Moderate ROM. No bruising or edema noted.
RESULTS
X-rays of the neck reveal no fractures.
ASSESSMENT
Neck sprain.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I recommended an MRI for further evaluation. I have also prescribed the patient Robaxin 1500 mg every 6 to 8 hours to treat his pain. I have also advised him to utilize ice, a heating pad, IcyHot, or Biofreeze on his neck as needed. I have also provided him with a home exercise program to work on his range of motion. I advised the patient that he will not be able to work until we have the MRI results.
INSTRUCTIONS
The patient will follow up with me after his MRI for results. |
D2N128 | virtassist | [doctor] hi , carolyn . how are you ?
[patient] good . how are you ?
[doctor] i'm good . you're ready to get started ?
[patient] yes , i am .
[doctor] so carolyn is a 49-year-old female here for follow-up of her chronic problems . so , how are you doing , carolyn ?
[patient] i'm doing okay . um , my osteoarthritis has been flaring up a little bit lately , um , so i wan na get- talk about that primarily . so , it's mostly in um , my elbows and it's really been bothering me . i've been sitting at the computer , at the desk more , um , in the office so i do n't know if it's being stagnant in that position all day has um , increased flare-ups for that , but i wanted to talk to you about that .
[doctor] okay , sure . and , are you right or left-handed ?
[patient] i'm right-handed .
[doctor] okay , and does one elbow bother you more than the other ?
[patient] my right elbow does bother me more than the other , but primarily , i'm typing all day versus writing , so it- it flares up in both .
[doctor] okay . all right , and um , any other joint pain ?
[patient] no , just- just really focused on my elbows .
[doctor] okay , and any numbing or tingling in your hands ?
[patient] uh , sometimes . when i'm typing for long periods of time , i feel a little bit of numbing , um , i try to shake out my arms a little bit . um , just to kind of relieve that um , sensation .
[doctor] okay . all right , and i know that you've had this also , had this history of gout . and the last episode you had was about three months ago . you had some inflammation of your toe . have you had any other issues with that ?
[patient] no , i have n't . um , the medication you gave me really controlled it , and i have n't seen a flare-up since .
[doctor] okay . all right , and how are you doing with your psoriasis ?
[patient] that's been under control too . that has n't been a- a major problem for me either .
[doctor] okay . i- i know that we had given you some clobetasol for your scalp . is that- so that's doing okay ?
[patient] yeah , that's doing a lot better .
[doctor] okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you .
[patient] okay .
[doctor] let's first look at your vital signs . hey , Sarah , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ?
[patient] yeah , that does hurt .
[doctor] okay , and when i turn your arm , do you have pain ?
[patient] yeah , that hurts a bit too .
[doctor] okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ?
[patient] yeah , it does and it's a bit stiff too .
[doctor] okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , Sarah . show me the autoimmune labs . hey , Sarah . show me the autoimmune profile . hey , Sarah . show me the esr . okay , so that's good . hey , Sarah . show me the uric acid . okay . all right , well , good . that's great . so , you know , it does n't look like you have any systemic arthritis , or sys- systemic inflammatory in process going on . so , my impression of you at this time is that from a gout standpoint , everything is nice and stable . i think that we should continue you on the colchicine 0.6 milligrams twice a day as needed for flare-ups of your gout . um , and then for your osteoarthritis , i'd like to go ahead and order a right elbow x-ray . hey , Sarah . order a right elbow x-ray , and then i'd like to prescribe some meloxicam 15 milligrams once a day for the pain and the swelling .
[patient] okay .
[doctor] hey , Sarah . order meloxicam 15 milligrams once a day . and then i'd like to um , just see those- how- the x-ray show- shows up and the results of that before we refer you for any type of physical therapy , okay ?
[patient] okay .
[doctor] and then from a psoriasis standpoint , i think everything is stable . we'll continue you on the steroid cream for your scalp , okay ?
[patient] that sounds good .
[doctor] all right , do you have any questions ?
[patient] no , that's it .
[doctor] all right , take care .
[patient] thank you .
[doctor] hey , Sarah . finalize the note .
| CHIEF COMPLAINT
Follow-up of chronic problem.
HISTORY OF PRESENT ILLNESS
Ms. Carolyn Garcia is a 49-year-old female who presents to the clinic today for follow-up of her chronic problem.
The patient reports her osteoarthritis has been flaring up a little lately, and she would like to talk about that, primarily in her elbows. She states she has been sitting at the computer more in the office, so she is unsure if it is stagnant in that position all day. She notes her right elbow bothers her more than her left elbow, but she is primarily typing all day versus writing. She denies any other joint pain. She notes occasional numbness and tingling in her hands, which she tries to shake out her arms to relieve the numbness.
She also has a history of gout. Her last episode was about 3 months ago. She had some inflammation of her toe at that time. She denies any other issues with that. She states the medication she was given at that time helped with her gout and she has not seen a flare up since. She reports her psoriasis is under control and has not been a major problem for her either. She is still on colchicine 0.6 mg twice a day as needed for flare-ups of her gout.
REVIEW OF SYSTEMS
• Musculoskeletal: Endorses joint pain.
• Neurological: Endorses numbness and tingling.
PHYSICAL EXAMINATION
• Neck: Supple without lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm.
• Gastrointestinal: Abdomen is soft.
• Musculoskeletal: No edema to the lower extremity. Examination of the right elbow, there is some edema and inflammation of the right olecranon. Some tenderness to palpation of the olecranon bursa. Pain with pronation and supination. Pain with flexion and extension of the right arm.
ASSESSMENT AND PLAN
A 49-year-old female here today for followup of chronic problem.
1. Gout
• Medical Treatment: Continue colchicine 0.6 mg twice a day as needed for flare ups.
2. Osteoarthritis
• Medical Treatment: We will order a right elbow x-ray. We will prescribe meloxicam 15 mg once a day for pain and swelling.
3. Psoriasis
• Medical Treatment: Continue steroid cream.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N129 | virtassist | [doctor] good afternoon , beverly . good to see you .
[patient] nice to see you too .
[doctor] so , i know my nurse told you a little bit about dax . um , now , if you do n't mind , i'd like to tell dax a little bit about you .
[patient] go for it .
[doctor] great . um , beverly's a 24 year old female patient , and i know you have a history of type 2 diabetes and high blood pressure . correct ?
[patient] yep .
[doctor] okay . so , you're here today for your yearly exam . have n't seen you in a year . how're you doing ?
[patient] i've been doing well . i began working in a bakery this summer which has been super fun. i have really been enjoying working there, but i find myself, since i am so close to so many delicious treats, snacking a lot during shifts and eating a lot more desserts than i normally would.
[doctor] okay , so , that brings me to your diabetes . so , how have your blood sugars been ?
[patient] uh , not so good .
[doctor] okay .
[patient] so , they've been up and down because of my diet , i think , because i've been taking my medication as prescribed . um , so , i have n't missed anything there , but my diet has been pretty bad lately .
[doctor] pretty bad lately ?
[patient] yeah .
[doctor] okay . and , that's really the only thing that's different is your diet , pretty much ?
[patient] yeah .
[doctor] and , that's because of the new job and all that ?
[patient] yeah. it has been really challenging to resist the temptation.
[doctor] it's hard to ignore those desserts , are n't they ?
[patient] yeah .
[doctor] no willpower like me ?
[patient] no , no willpower .
[doctor] okay . all right . and , and then , um , i know you've had high blood pressure , hypertension . how is , how have your blood sugars been ? have you been checking them ?
[patient] so , my blood pressure's been good . um , despite my , um , my diabetes levels being up and down .
[doctor] okay .
[patient] so , that's been good .
[doctor] okay , so , your blood pressures have been normal . you've been sleeping well ?
[patient] yep , getting a full eight hours .
[doctor] no concerns about hurting yourself or anything like that ?
[patient] no .
[doctor] okay , good . okay , and i know my , um , nurse did a review of systems . other than what we've talked about so far , is there anything else that you needed to add ?
[patient] no .
[doctor] good . so , pretty much status quo except for those things that we've been working on , right ?
[patient] yep .
[doctor] okay , good . all right . well , let me do a quick physical exam , okay ?
[patient] okay .
[doctor] okay , squeeze my finger here . good . can you feel me touch out here ?
[patient] yep .
[doctor] okay . and , can you feel me touch you down here ?
[patient] yep .
[doctor] okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ?
[patient] yes , i am .
[doctor] okay , and you take that twice a day ?
[patient] yep .
[doctor] okay . um , uh , hey , Sarah ? show me the vital signs . okay , good news here is your blood pressure's good . everything , um , there is fine . so , um , so , my assessment is , is , um , your first problem is diabetes . it's a little out of control . we'd like that hemoglobin a1c to be under seven , um , at least . you know , preferably , under six .
[patient] mm-hmm .
[doctor] so , um , uh , i'm not gon na change your medication . i think this is diet related , so i want you to try to cut down on the snacking and additional sweets , okay ?
[patient] yeah .
[doctor] and , i want you to check your blood sugars in the morning . i want you to call them in in about two weeks so we know what your first , um , fasting blood sugar was in the morning , and then , we'll come back and see you in about two months and see if everything has straightened out . if it has n't , then we'll talk about adding another medication , okay ?
[patient] okay .
[doctor] your second problem is your hypertension . that seems to be relatively stable . i want you to stay on your current medication . you're on li- lisinopril 10 mg once a day . just stay right on that medication . no changes at this point . seems to be doing well , okay ?
[patient] okay .
[doctor] good . anything else i can do for you today ?
[patient] no . that's it .
[doctor] good . come with me , we'll get you checked out .
[patient] thank you .
[doctor] hey , Sarah ? finalize the note . | CHIEF COMPLAINT
Annual exam.
HISTORY OF PRESENT ILLNESS
Beverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.
The patient states she has been doing well. She has recently began working at a bakery this summer.
The patient states her diabetes is uncontrolled. Her blood sugars have fluctuated recently, which she attributes to her change in diet due to work. She is trying to improve her diet by removing additional sweets. She has been taking her medication as prescribed and has not missed any doses.
The patient states her blood pressure has been good despite her blood sugar levels being up and down. She has continued taking metformin twice a day.
She has been sleeping well and is able to sleep a full 8 hours. She denies thoughts of self-harm or suicidal ideations.
PHYSICAL EXAMINATION
• Neurological/Psychological: Grip strength equal bilaterally. Neurologically intact.
• Neck: Supple without thyromegaly or lymphadenopathy. No carotid bruits appreciable.
Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate. Grade 2/6 systolic ejection fraction murmur. No gallops or rubs. No extra heart sounds. Good pulses.
RESULTS
Hemoglobin A1c is elevated.
ASSESSMENT AND PLAN
Beverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.
Diabetes mellitus type 2.
• Medical Reasoning: Her blood glucose levels have been uncontrolled. She is still taking metformin twice a day, but does admit to dietary indiscretion with an increase in her sweets intake.. Her most recent hemoglobin A1c was elevated.
• Medical Treatment: Continue metformin twice a day.
• Patient Education and Counseling: I encouraged her to check her fasting blood glucose levels each morning and call them in about 2 weeks. She will follow up in about 2 months, at which time we will discuss further treatment recommendations.
Hypertension.
• Medical Reasoning: Appears to be relatively stable.
• Medical Treatment: Continue lisinopril 10 mg once daily.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N130 | virtassist | [doctor] hi , anna , how are you ?
[patient] i'm doing okay . how are you ?
[doctor] i'm doing well . uh , so i know the nurse told you a little bit about dax . i'd like to tell dax a little bit about you .
[patient] okay .
[doctor] all right . so , uh , anna is a 26-year-old female with a past medical history , significant for epilepsy , depression , and , uh , peptic ulcer disease , who presents with , uh , some joint pain . so , anna , what's going on with your , uh , what's going on with your joints ?
[patient] so , um , it's my left elbow that's really been bothering me . uh , i sit at my desk a lot for work , and type , and i stay in this motion specifically all day . and then after , um , work , it's really hard for me to , uh , open and , and close my , my elbow here , my left elbow , and it's been just really stiff and , and hurts .
[doctor] okay . have you noticed any swelling there on the-
[patient] yeah , i have .
[doctor] okay , and is it right here on the , on the tip ?
[patient] yep , it is .
[doctor] okay , and are you right or left-handed ?
[patient] i am right-handed .
[doctor] okay , so it's your non-dominant hand ?
[patient] yeah , which is good .
[doctor] yeah .
[patient] so , i can still write , which is great , but typing is , is difficult .
[doctor] okay , and any numbing or tingling in your hands at all ?
[patient] no , i have n't felt numbing or tingling .
[doctor] and any weakness in your arm ?
[patient] a little bit of weakness , uh , but nothing too significant .
[doctor] okay , and ... and how about ..
[doctor] and how about , um , any fever or chills ?
[patient] no fever or chills .
[doctor] okay . all right , well , let's talk a little bit about your epilepsy , okay ?
[patient] okay .
[doctor] um , have you had any recent seizures ?
[patient] uh , no , i have n't . i think my last seizure was a year ago .
[doctor] okay , good .
[patient] yeah .
[doctor] and you're still taking the keppra ?
[patient] yes , i am .
[doctor] okay , great . and then , tell me a little about your depression . how're you doing with that ? i know that you went into therapy last year , and you tried to avoid medication since you're already on the keppra . how's that doing ?
[patient] uh , therapy , therapy's been good . it , it has definitely helped . uh , i still feel a little down , uh , and , and stressed .
[doctor] okay . all right , but no , no feelings of wanting to hurt yourself or somebody else ?
[patient] no , nothing like that .
[doctor] okay . all right . and then , how are you doing with your , with your ulcer ? i know that you , you know , you had so much stress a year ago and , you know , you were having some issues there . we did the endoscopy-
[patient] mm-hmm .
[doctor] . and they showed that . so , how are you doing with that ?
[patient] i'm doing , i'm doing better . i have n't had any , um , issues with that , um , since we did the procedure , and everything's been good .
[doctor] okay , well great . let's go ahead and ... i'm gon na go ahead with , um ... and , you know , i know that the nurse did a review of systems sheet on you when you came in , and i know that you were endorsing that left elbow pain .
[patient] mm-hmm .
[doctor] any other symptoms , you know , chest pain , shortness of breath , abdominal pain , nausea or vomiting ?
[patient] no , nothing like that . i have a little bit of nasal , nasal congestion from allergies , uh , but that's it .
[doctor] okay , so you're endorsing some nasal congestion ?
[patient] yeah .
[doctor] okay . all right , well , let's go ahead to a physical exam , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the vital signs . good , here in the office , everything looks great with your vital signs . i think that's great , so i'm just gon na take a listen to your heart and your lungs , and take a look at your elbow and , and we'll go from there , okay ?
[patient] okay .
[doctor] all right , so , so on physical examination of your left elbow , you do have some erythema and edema of your left elbow . does it hurt when i touch ?
[patient] yeah , it does .
[doctor] okay , he ... she has some pain to palpation of the olecranon . of the left olecra- olecranon , and it is warm to palpation . um , can you straighten your elbow for me ?
[patient] yeah , it , it hurts , and it's , uh , it's a bit stiff .
[doctor] okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the left elbow x-ray . hey , Sarah , show me the elbow x-ray . hey , Sarah , show me the left arm x-ray . okay , so , in reviewing the results of your left arm x-ray , there's no evidence of any elbow fracture , which is not surprising , okay ?
[doctor] hey , Sarah , show me the endoscopy results . hey , Sarah , show me the endoscopy . okay , well , your recent endoscopy showed that you ... hey , Sarah , show me the endoscope . all right , so here it looks like , you know ... your endoscopy results look like you had an episode of gastritis . that's for your , your peptic ulcer disease , and so everything , you know ... you took your , your protonix , and i think everything resolved at that point , okay .
[patient] okay .
[doctor] so , let's talk a little bit about my assessment and my plan for you . so for your first problem , this left elbow pain , you know , i think you have olecranon bursitis , and we're just gon na , you know , have you , you know , get a little pillow for your elbow there . it's just caused by repetitive trauma .
[patient] mm-hmm .
[doctor] so , maybe you're slamming your elbow down a little bit on the desk , so just get a little rest there-
[patient] yeah .
[doctor] . and we'll give you some melo- meloxicam , 15 mg , once a day . you can ice the area , okay ? um , for your next problem , the epilepsy , sounds like you're doing really well . i would go ahead and continue with the keppra , 500 mg , twice a day . do you need a refill of that ?
[patient] yes , i do .
[doctor] hey , Sarah , order a refill of keppra , 500 mg , twice daily . for your third problem , the depression , it sounds like you're doing well with the therapy and , if you want , we can talk about medical treatment options .
[patient] yeah , i think that would be great .
[doctor] okay , well , let's go ahead and we'll start you on some lexapro , 10 mg , once a day , and we'll see how you do on that , okay ?
[patient] okay .
[doctor] all right , and then , for your last problem , the peptic ulcer disease , um , i want you to continue on the protonix , 40 mg , once a day before meals , okay ?
[patient] okay .
[doctor] do you have any questions ?
[patient] no , i do n't .
[doctor] okay . all right . well , the nurse will come in soon and see you , okay , and i'll , i'll see you in a couple of weeks .
[patient] okay .
[doctor] all right , take care . bye .
[patient] bye .
[doctor] hey , Sarah , finalize the note . | CHIEF COMPLAINT
Joint pain.
HISTORY OF PRESENT ILLNESS
The patient is a 26-year-old female with a past medical history significant for epilepsy, depression, and peptic ulcer disease who presents with some joint pain.
The patient reports that her left elbow has really been bothering her. She states that she sits at her desk all day for work with her elbows bent. She reports that after work it is really hard for her to flex and extend her left elbow. She reports that it has been really stiff and painful. She also notes that she has noticed swelling on the olecranon of her elbow. She reports that she is right-handed, therefore, she can still write, which is great, but typing is difficult. She denies any numbness or tingling in her hands. She reports that she has some weakness in her arm but nothing too significant. She denies any fever or chills.
Regarding her epilepsy, she reports that she has not had any recent seizures. She reports that her last seizure was a year ago. She reports that she is still taking Keppra.
Regarding her depression, she reports that she started therapy last year and she is trying to avoid medications for this problem. She reports that therapy has been helpful, but she still feels down and stressed. She denies suicidal and homicidal ideations.
Regarding her peptic ulcer, she reports that she was dealing with a lot of stress last year. She then underwent an endoscopy which showed that she had an episode of gastritis. She was subsequently diagnosed with peptic ulcer disease and started Protonix. She reports that she has not had any issues with her ulcer since the procedure and everything has been good.
The patient denies chest pain, shortness of breath, abdominal pain, nausea, or vomiting. She reports that she does have a little bit of medial nasal congestion from allergies.
REVIEW OF SYSTEMS
• Ears, Nose, Mouth and Throat: Endorses medial nasal congestion from allergies.
• Cardiovascular: Denies chest pain or dyspnea on exertion.
• Respiratory: Denies shortness of breath.
• Musculoskeletal: Endorses left elbow joint pain, swelling, and weakness.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Musculoskeletal: Examination of the left elbow reveals erythema and edema. Pain to palpation of the left olecranon. Warm to palpation. Pain with flexion and extension. Palpable left radial pulse.
RESULTS
Left arm x-ray does not reveal any evidence of elbow fracture.
EGD revealed an episode of gastritis.
ASSESSMENT
Anna Morris is a 26-year-old female with a past medical history significant for epilepsy, depression, and peptic ulcer disease who presents with some joint pain.
PLAN
Left elbow pain.
• Medical Reasoning: I believe she has left olecranon bursitis caused by repetitive trauma.
• Medical Treatment: Initiate meloxicam 15 mg once daily.
• Patient Education and Counseling: I encouraged the patient to use a pillow to rest her arm on. She may also ice the area.
Epilepsy.
• Medical Reasoning: She has been doing well on Keppra and denies any recent seizures.
• Medical Treatment: Continue Keppra 500 mg twice a day. This was refilled today.
Depression.
• Medical Reasoning: She reports doing well with therapy.
• Medical Treatment: Initiate Lexapro 10 mg once daily.
Peptic ulcer disease.
• Medical Reasoning: Her recent endoscopy revealed gastritis
• Medical Treatment: Continue Protonix 40 mg once daily before meals.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N131 | virtassist | hi , susan , how are you ?
[patient] good . how are you ?
[doctor] good . are you ready to get started ?
[patient] yes , i am .
[doctor] so , susan is a 26-year-old female here for a high blood pressure check . susan , what's going on with your blood pressure ?
[patient] so , i've always struggled with , um , high blood pressure , but it's seeming to get really out of control lately . so , i wanted to come in and see if there's any type of new medication i can be on to help it get steady or if there is diet restrictions i should take , um , things like that .
[doctor] okay . so , i know that we've had you on the norvasc and we had to increase your dose , so you're on 10 milligrams a day now . and what are your blood pressures running at home ? you c- ... like , have they been like over 150 ?
[patient] yeah , they have been .
[doctor] okay . all right . and , have you had any headaches ?
[patient] i have had some headaches . i do n't know if that's just because of more stress at work or , um , because of the high blood pressure .
[doctor] okay . all right . so , you've had some headaches . have you had any chest pain , shortness of breath , anything like that ?
[patient] no , nothing like that .
[doctor] okay . um , and , you know , i know that you've had a kidney transplant a few years ago .
[patient] yes .
[doctor] everything is okay with that ?
[patient] everything's been good and solid there .
[doctor] and you're taking all of your auto , um , i- um , your immunosuppression medications ?
[patient] yes , i am .
[doctor] all right .
so , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , uh , left plank for your kidney transplant which is healed . and you have no lower extremity edema . so , let's go ahead and look at some of your results , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the creatinine . so , your kidney function looks really good . so , that's really promising after your transplant . hey , Sarah , show me the ekg . and your ekg looks great , uh , perfectly normal , so that's good . um , so , my impression of you at this time ... , let me see your blood pressure .
[patient] okay .
[doctor] hey , Sarah , show me the blood pressure . yeah , and you're right , it-
[patient] hm .
[doctor] . it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ?
[patient] okay .
[doctor] hey , Sarah , order carvedilol 25 milligrams , twice a day . uh , i'd also like to go ahead and , uh , get a lipid panel and some routine labs on you just to make sure that everything is okay .
[patient] yeah .
[doctor] hey , Sarah , order a lipid panel . hey , Sarah , order a complete metabolic panel . all right . and then , um , from a transplant standpoint , everything looks fine . your kidney function looks great , so we're just gon na continue you on all of those medications .
so , the nurse will come in soon and she'll help you schedule all of the al- schedule a follow-up appointment with me , and we'll see what your blood pressure looks like in a couple weeks after taking that medication . okay ?
[patient] okay .
[doctor] all right . thanks , susan .
[patient] thank you .
[doctor] hey , Sarah , finalize the note . | CHIEF COMPLAINT
High blood pressure check.
HISTORY OF PRESENT ILLNESS
Ms. Susan Watson is a 26-year-old female who presents to the clinic today for a high blood pressure check.
The patient reports she has always struggled with high blood pressure, but it is seems out of control recently. She notes that she has interest in new medication or diet changes to help. She is currently on Norvasc 10 mg daily. Her blood pressure at home has been over 150. She notes she has had some headaches, but she is unsure if it is due to stress at work or her high blood pressure. She denies chest pain or shortness of breath.
The patient underwent a kidney transplant a few years ago, and everything is going well. She is taking all of her immunosuppression medication.
REVIEW OF SYSTEMS
• Cardiovascular: Denies chest pain or dyspnea on exertion.
• Respiratory: Denies shortness of breath
• Neurological: Endorses headaches.
PHYSICAL EXAMINATION
• Constitutional: in no apparent distress.
• Neck: Supple without thyromegaly or lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: 2/6 systolic ejection murmur.
• Musculoskeletal: No edema.
• Integumentary: Scar on left flank from kidney transplant, healed.
RESULTS
Creatinine: normal.
Electrocardiogram: normal.
ASSESSMENT AND PLAN
Ms. Susan Watson is a 26-year-old female who is here today for a high blood pressure check.
Hypertension.
• Medical Reasoning: Her blood pressure is elevated today and based on her recent home monitoring.
• Additional Testing: I would like to get a lipid panel and metabolic panel.
• Medical Treatment: carvedilol 25 mg twice a day to help bring her blood pressure down.
Status post kidney transplant.
• Medical Reasoning: Doing well.
Kidney function stable.
• Medical Treatment: Continue current medications.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N132 | virtassist | [doctor] hello mrs. lee , i see you're here for back pain .
[patient] yes .
[doctor] hey Sarah , i'm seeing mrs. lee today for , uh , back pain . she's a 40-year-old female . so can you tell me what happened to you ?
[patient] yes . i was at a birthday party and it was surprise party . so we were all like crunched behind and hiding . and when the person came in we all jumped out , and then i fell down the little stair and i rammed my back into the railing of the s- , uh , staircase .
[doctor] so it was a surprise for you too ?
[patient] yes it was .
[doctor] very good . okay . so , um , did it hurt because you hit it , or did you twist ? what happened when you ?
[patient] i think it was my motion-
[doctor] okay .
[patient] . of jumping up , or something .
[doctor] okay .
[patient] and maybe a twisting .
[doctor] okay . any pain shooting down your legs at all ?
[patient] no .
[doctor] is it on one side or the other of your back ?
[patient] um , it's more on the right .
[doctor] on the right . is there anything that makes it better or worse ?
[patient] uh , if i'm lying flat it hurts a little more , and any twisting motion for sure .
[doctor] okay . all right . and do you have any history or any back problems before ?
[patient] i did . i had a fusion done .
[doctor] okay , yeah that lumbar fusion . um , let's take an x-ray . hey . or let's look at an x-ray . hey Sarah , show me the latest x-ray . okay , we can see where you had your fusion , t4 here on the x-ray . but i do n't see anything that looks , um , significantly abnormal . it does n't appear to have any compression fractures or anything like that . so , it's essentially , except for the fusion , a normal exam . let me do your exam for you here . can i have you stand up please ? does it hurt when i twist you that way ?
[patient] yes .
[doctor] okay . you can sit back down . if i lift your leg here , does that bother you ?
[patient] no .
[doctor] how 'bout when i lift this leg ?
[patient] no .
[doctor] any pain shooting down your legs when i do that ?
[patient] no .
[doctor] okay . and can you feel me touching down here .
[patient] yes .
[doctor] okay , great . so , you had a injury to your back when you were twisting at the birthday party . you do n't really have any pain or numbness down your legs . you have some stiffness with rotation , um , but you do n't have any evidence of a , um , what we would call a pinched nerved or radiculopathy . so , i think you basically have a strain of your lower back . um , have you been taking any medications ?
[patient] just some ibuprofen .
[doctor] okay . and do you have any other , um , medical problems ?
[patient] um i take medication for anxiety .
[doctor] okay . and that's all ? okay . um , so what we're gon na do is i'm gon na give you , um , just continue the motrin at 800mg , three times a day , with food . i want you to use some ice and heat , alternating on your back . but i do want you walking .
[patient] okay .
[doctor] um , and , uh , this should sort of take care of itself after a few days . if it's not , or it's getting worse , i want you to come back and see me over the next week .
[patient] okay .
[doctor] does that sound good ?
[patient] it does .
[doctor] okay , Sarah . hey Sarah , go ahead and order the medications and procedures and close out the note . come on i'll bring you out to check out .
[patient] thank you . | CC:
Back pain.
HPI:
Ms. Lee is a 40-year-old female who presents today for an evaluation of back pain. She states she was at a birthday party and she ran her back into the railing of the staircase and twisted her back. She denies any pain radiating down her legs. Lying flat and twisting motions aggravate the pain. She is currently taking ibuprofen.
CURRENT MEDICATIONS:
Ibuprofen.
PAST MEDICAL HISTORY:
Anxiety.
PAST SURGICAL HISTORY:
Lumbar fusion
EXAM
Examination of the back shows range of motion without pain. Straight leg raise is negative. Sensation is intact.
RESULTS
X-rays of the lumbar spine show no obvious signs of acute fracture. Evidence of a prior lumbar fusion with hardware in good position.
IMPRESSION
Lumbar spine strain.
PLAN
At this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and heat. She will continue with Motrin 800 mg 3 times a day with food. She will follow up with me as needed.
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D2N133 | virtassist | [doctor] good morning rebecca , nice to see you .
[patient] nice to see you too .
[doctor] so , my nurse told you a little bit about dax , now i'm wondering if i can tell dax a little bit about you .
[patient] go for it .
[doctor] okay , so rebecca is a 27-year-old female patient . um , you have a history of carpal tunnel , um , uh , release done couple of years ago , you have some chronic back pain , some depression . why am i seeing you today ?
[patient] so last week , um , and over the course of the month , i have taken up swimming more regularly .
[doctor] okay .
[patient] i've been trying to get up and get active . and i've- ... all of a sudden i've been feeling some really bad , um , knee pain-
[doctor] okay .
[patient] . in my right knee .
[doctor] just in your right knee ?
[patient] yeah .
[doctor] okay . just when swimming ? are you swimming freestyle with your legs kicking straight or more like breaststroke where your legs kick out ?
[patient] yeah , it's only while swimming. i use the breaststroke so i guess where the legs are kicking out like a frog ... it kinda starts hurting a little bit after i swim a couple laps , which a month ago when i started i was able to do ten .
[doctor] okay .
[patient] but after a couple of laps it starts to hurt .
[doctor] and no injury ? like you did n't fall or twist it or anything like that that you remember ?
[patient] no , not that i can remember .
[doctor] okay . so just swimming a lot and you feeling more and more discomfort ?
[patient] yeah .
[doctor] okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ?
[patient] yeah , it comes and goes , but right now it's been doing really well .
[doctor] okay , no pain going down your legs or anything like that ?
[patient] no .
[doctor] okay . and i know you have some depression , you've been on medication . how's that been going ?
[patient] that's been going really well .
[doctor] okay .
[patient] with the medication and therapy and then trying to get outside more it's been really helping me .
[doctor] sleeping well ?
[patient] yeah .
[doctor] eating well ? okay . do n't feel any concerns about hurting yourself or others or anything like that ?
[patient] no .
[doctor] okay , good . um , and the , you had ca- carpal tunnel done a few years ago . how's that doing ?
[patient] that's doing-
[doctor] any flare up with that ?
[patient] . that's doing really well . i've been getting full range of motion and it's felt a lot better .
[doctor] okay , great . do you mind if i do a quick exam ?
[patient] yeah , go for it .
[doctor] squeeze my fingers for me . good . okay . is it painful if i move your patella like that ?
[patient] yeah , that hurts .
[doctor] okay . and i'm gon na hold your leg out , i'm gon na hold , i want you to stiffen your upper ... does that hurt when i do that ?
[patient] yeah , that hurts too .
[doctor] okay , good , all right . um , let's take a quick look at your x-ray , okay ?
[patient] okay .
[doctor] hey Sarah , show me the right knee x-ray . okay , so here's a picture of your right knee . actually normal x-ray , everything looks good , okay ? on my exam , um , you do n't really have any swelling in- in your joints , um , uh , of your knee . you have a little pain with , um , uh , range of motion of the knee . you have real pain when we do what we call patella in- ... patellar inhibition , okay ? so that's what caused most of that pain . so , um , your heart is regular , your lungs are clear , i do n't feel any adenopathy , your thyroid's , um , normal , your grips are equal , the rest of your exam is essentially normal , okay ? so my assessment is , you have what we call chondromalacia of the patella , okay ? it's just from the overuse and all- all the swimming you've been doing , okay ? so , um , to treat that we'll just use some anti-inflammatories , um , go ahead and take some ibuprofen , 600 milligrams four times a day with food . i do want you to do some straight leg raising exercises , that'll strengthen your quadriceps and that'll help with that pain , okay ?
[patient] okay .
[doctor] um , basically you want to avoid anything that puts extra pressure on your knees for a little while and it should be fine . if it's not getting any better in a couple weeks i wan na see you again , okay ? so no lunges , avoid the breaststroke . if you're comfortable, you can also do other swimming strokes where your knees are straight instead . or you can take the opportunity to have a little break .
[patient] all right .
[doctor] your second problem is your chronic back pain , that's been doing really well . um , keep swimming , that's okay after this gets better .
[patient] yeah .
[doctor] um , but i think , um , i think that's been under control . but if it flares up go ahead and , uh , give me a call , okay ?
[patient] mm-hmm .
[doctor] um , your third problem is your depression . that's been stable . we're gon na keep you on your current medication , not gon na change anything at this point , okay ? and as far as your carpal tunnel goes , that's relatively stable , so , um , uh , no changes there as well . okay ? so anything else i can do for you ?
[patient] no , that's it .
[doctor] okay , well we'll get you checked out .
[patient] all right .
[doctor] hey Sarah , finalize the report .
| CHIEF COMPLAINT
Joint pain
HISTORY OF PRESENT ILLNESS
Ms. Thompson is a 27 y.o. female with a history of carpal tunnel release done a couple years ago, chronic back pain, and depression. She presents today for joint pain.
Ms. Thompson reports that over the course of the month she has begun swimming more regularly and trying to be more active. She has experienced bad right knee pain. The patient reports that her knee starts hurting after a couple of laps. She notes previously she could swim 10 laps. She denies injury or trauma to the knee.
The patient has a history of chronic back pain that has been intermittent, but right now it has been doing well. She denies pain radiating down her legs.
The patient has a history of depression, which has been going really well with medication and therapy. She is trying to get outside more and it has been helping her with her depression. She notes she is sleeping and eating well. She denies concerns about hurting herself or others.
The patient's carpal tunnel is doing really well. She has been getting full range of motion and it has felt a lot better.
REVIEW OF SYSTEMS
• Musculoskeletal: Endorses right knee joint pain. Endorses chronic back pain.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Neurological/Psychological: Appropriate mood and affect. Grips are equal bilaterally.
• Neck: Supple without thyromegaly or cervical lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.
• Musculoskeletal: No lower extremity edema. Pain with patellar inhibition. Pain with range of motion of the right knee.
RESULTS
X-ray of the right knee is unremarkable.
ASSESSMENT AND PLAN
Ms. Thompson is a 27 y.o. female who presents today for evaluation of right knee pain.
Chondromalacia of right patella.
• Medical Reasoning: She has been more active lately but is unaware of any injury to the knee. Her recent x-rays were normal but she did have some discomfort on exam.
• Medical Treatment: Prescribed ibuprofen 600 mg 4 times a day with food. I do want her to do some straight leg raising exercises that will strengthen her quadriceps.
• Patient Education and Counseling: I encouraged her to participate in physical activity that is less straining on her joints , such as swimming freestyle laps, or to stop activity all together. If her pain does not improve in a couple of weeks, she will follow up.
Chronic back pain.
• Medical Reasoning: This is stable and well-controlled at this time.
• Medical Treatment: She should continue swimming regularly once her knee is feeling better.
Depression.
• Medical Reasoning: She is doing well with her current regimen.
• Medical Treatment: Continue current medications.
Carpal tunnel syndrome.
• Medical Reasoning: Relatively stable status post carpal tunnel release.
• Medical Treatment: Continue current regimen with no changes at this time.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N134 | virtassist | [doctor] we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ?
[patient] i'm good . how are you ?
[doctor] i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ?
[patient] okay .
[doctor] all right . so , michelle is a 31-year-old female with a past medical history of type 2 diabetes and hypertension who presents with abnormal lab finding . so , michelle , it came back to me that you had had a positive long ... lyme titer .
[patient] yeah .
[doctor] and so , uh , can you , you , you know , can you tell me a little bit about it ? i know the last time i saw you , you had had an insect bite , and you know , it came back positive for lyme . so how are you feeling ?
[patient] i've been feeling ... i could feel better . um ... i've been feeling tired , um , really lacking a lot of energy , and i have swollen joints in my elbows , just really hurts .
[doctor] okay . all right . and have you had any , any body aches ?
[patient] yeah , i have .
[doctor] okay . all right . um , and i know that you were out hiking in the woods and , and that type of thing a couple of weeks ago , and we thought that that's where you got the bite . so , um , how's your , how's your appetite ? have you been okay ? a little nauseous ?
[patient] yeah , i've been a little nauseous . i have n't been able to eat much . i've been trying just to keep , you know , toast and crackers and that's all about i've been able to stomach , really .
[doctor] okay , and , and i know that you had had that , that , uh , bite there . have you noticed any other rash anywhere else ?
[patient] yeah , i have .
[doctor] okay . all right . sometimes they kind of describe it as looking as like a bull's-eye .
[patient] yes .
[doctor] is that what it looked like ?
[patient] mm-hmm .
[doctor] okay . all right . well , um , have you had any , any high fevers ?
[patient] uh , no , not that i've noticed .
[doctor] all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?
[patient] they've been okay . i've noticed that they sometimes get a little high and a little low . um , but nothing too far out of range .
[doctor] okay . all right . um , and you're still taking the metformin ?
[patient] yes .
[doctor] okay . all right . good . and then in terms of your high blood pressure , are you monitoring the blood pressures at home ?
[patient] yeah , i , i have a ... i bought a cuff last year , and i've been , um , taking it myself at home . those have looked good . i've been staying away from the salty foods .
[doctor] mm-hmm .
[patient] um , so that's been good .
[doctor] okay . and , um , so you're still taking the lisinopril ?
[patient] yes .
[doctor] okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ?
[patient] no , nothing like that .
[doctor] okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam .
[patient] okay .
[doctor] hey , Sarah , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ?
[patient] okay .
[doctor] okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ?
[patient] yeah , it does .
[doctor] okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ?
[patient] no , no pain for that .
[doctor] non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ?
[patient] okay .
[doctor] so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ?
[patient] okay .
[doctor] i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ?
[patient] okay .
so for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ?
[patient] okay .
[doctor] hey , Sarah , order a hemoglobin a1c . and for your last problem , your high blood pressure . it looks today like everything is fine . i think you're doing a really good job of managing your hypertension , and i'm going to continue you on the lisinopril , 10 milligrams a day , and i'm gon na go ahead and order a lipid panel , and , um , i want you to continue to record your blood , blood pressure regularly , okay ?
[patient] okay .
[doctor] all right . do you need a refill of that ?
[patient] uh , yes , i do .
[doctor] okay . hey , Sarah , order lisinopril , 10 milligrams daily . do you have any questions ?
[patient] no , i do n't .
[doctor] okay , so i'm gon na , you know , the nurse is gon na come in , and she's gon na check you out , and then we'll make a follow-up appointment for you , okay ?
[patient] okay .
[doctor] hey , Sarah , finalize the note . | CHIEF COMPLAINT
Abnormal labs.
HISTORY OF PRESENT ILLNESS
The patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs. She had an insect bite at her last visit after hiking in the woods. We drew a Lyme titer which came back positive.
The patient reports she has been feeling tired and lacking a lot of energy. She also notes swollen elbow joints, body aches, bullseye rash, and nausea. She states she has not been able to eat much. What she does eat has been bland foods such as crackers. She denies any high fevers.
Regarding her type 2 diabetes, she states her blood sugars have been okay. She notes they are sometimes a little high or low, but nothing too far out of range. She is still taking metformin.
Regarding her hypertension, she is monitoring her blood pressure at home and it has been good. She is avoiding salty foods and is still taking lisinopril.
The patient denies abdominal pain and diarrhea.
REVIEW OF SYSTEMS
• Constitutional: Denies fevers. Endorses fatigue.
• Gastrointestinal: Denies abdominal pain and diarrhea. Endorses nausea.
• Musculoskeletal: Endorses bilateral elbow joint swelling, pain. Endorses body aches.
• Integumentary: Endorses a rash.
PHYSICAL EXAMINATION
• Gastrointestinal: Examination of her abdomen reveals warmth to palpation. Nontender to palpation. No evidence of cellulitis.
• Musculoskeletal: Swelling and pain to palpation of elbow joints bilaterally.
• Integumentary: Small bullseye rash on the left abdominal quadrant.
RESULTS
Lyme titer: elevated.
Labs: WBC is within normal limits. All other labs are normal as well.
ASSESSMENT AND PLAN
The patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs.
Newly diagnosed Lyme disease.
• Medical Reasoning: This is a new issue for her. She presented with an insect bite at her last visit, and her subsequent lyme titer was elevated.
• Medical Treatment: I am going to prescribe doxycycline 100 mg twice a day for 3 weeks. I am going to touch base with an infectious disease doctor to ensure nothing else that needs to be done. I want to see her again next week for follow-up for this.
Hypertension.
• Medical Reasoning: This has been well-controlled based on home monitoring. She has been compliant with dietary modifications including limiting her sodium intake.
• Additional Testing: I am going to order a lipid panel.
• Medical Treatment: She will continue lisinopril 10 mg a day. This was refilled today.
• Patient Education and Counseling: I advised the patient to continue to regularly monitor her blood pressures at home.
Diabetes type 2.
• Medical Reasoning: She has noticed intermittent elevations of her blood glucose levels but has been compliant with the use of metformin. Her diet has been limited due to nausea in the setting of Lyme disease.
• Additional Testing: I am going to order a hemoglobin A1c to ensure no medication changes are needed.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N135 | virtassist | [patient] um , i have high blood sugar . yeah , osteoarthritis , arterial fibrillation , and reflux .
[doctor] hi , hannah . how are you ?
[patient] good , how are you ?
[doctor] i'm good . you ready to get started ?
[patient] yes , i am .
[doctor] so , hannah is a , uh , 52-year-old female here for evaluation of a high blood sugar . so , hannah , what ha- what happened ? i heard you were in the emergency room with a high blood sugar .
[patient] yes . so , i've been eating a ton of sweets recently . with the holidays it just feels like there is always something sweet available. whether i am at work and there are holiday gift baskets or clients bringing in treats or when i visit my family for the holidays and there is every baked good imaginable, there is always something sweet i can be eating. in the beginning i felt fine, but i have started to feel it after a couple of weeks, and this past week i just felt really light-headed and i could ... was seeing spots , really dizzy . so i went into the emergency room and they said i had a high blood sugar . um , so i wanted to come in and follow up with you to get that , um , get checked out .
[doctor] okay . all right . and how , how are you feeling now ? did they , did , did they treat you in the emergency room ? did they gi- they give you some iv fluids and things like that ?
[patient] yeah . they gave me some fluids and they told me just to try to really cut out eating any extra sweets and get back into my normal routine and diet, but i am still staying with my family, and my mom and grandmother are big bakers so i think it will be really hard to get into a routine there so i just want to make sure i am nipping this high blood sugar thing in the bud.
[doctor] okay . and i saw you went through a review of systems sheet with a nurse . i just want to ask you a few more questions from that standpoint . so you have had any fever or chills ?
[patient] no .
[doctor] any chest pain or shortness of breath ?
[patient] n- uh , no .
[doctor] abdominal pain ?
[patient] no .
[doctor] any burning when you urinate ?
[patient] no .
[doctor] any joint pain or muscle aches ?
[patient] no .
[doctor] okay .
[patient] i do have osteoarthritis though , so that , when i say , " no , " it's not , like , nothing out of the norm-
[doctor] okay .
[patient] . for me .
[doctor] perfect . um , and then , i know that you have this history of a-fib , atrial fibrillation . have you felt your heart racing at all , recently ?
[patient] only when i'm really anxious . i , i feel it , um , pumping a little bit . but other than that i have n't .
[doctor] okay . all right . and how are you doing with your reflux ?
[patient] i've been doing well . i've been taking the medication that you prescribed to me and that's been helping a lot .
[doctor] okay , yeah . i see here you're on the protonix , 40 milligrams , once a day .
[patient] yes .
[doctor] so that's , you're doing well with that ?
[patient] yep .
[doctor] okay . all right . so let's go ahead and do a quick physical exam . so , listening to you , um , look , or looking at you , you appear in no distress . your thyroid is a little enlarged , but non-tender . there's no carotid bruits , your heart is in irregular rate and rhythm , and your lungs are clear . your abdomen is nice and soft , and you have no edema in your lower extremities . let's go ahead and look at some of your test results .
[patient] okay .
[doctor] hey , Sarah ? show me the blood sugar . hey , Sarah ? show me the blood glucose . hey , Sarah ? show me the hemoglobin a1c . okay , so i see here that both your blood sugar and your hemoglobin a1c are elevated . so your blood sugars have probably been running high for probably a few months . okay ? um , let's go ahead and look at some of your other results . hey , Sarah ? show me the diabetes labs . yeah . okay . yeah , so , um , my impression of you at this time , um , for your high blood sugars , that you do have this diagnosis of diabetes . now , we're not sure if it's type i or type ii . even patients in , you know , in their mid-twenties can develop type i diabetes , so we're gon na go off and , we're gon na go ahead and , and send some labs to work that up . hey , Sarah ? order a complete metabolic panel . and i'd like to start you on metformin , 500 milligrams , twice a day . that will help keep your blood sugars down .
[patient] okay .
[doctor] hey , Sarah ? order metformin , 500 milligrams , twice a day . and then if some of the autoimmune labs that come back show that you have an autoimmune disorder , meaning that you would have type i diabetes , then we would have to go ahead and put you on insulin . but i'm gon na hold off until we have those results , okay ?
[patient] okay .
[doctor] but in the meantime , i really want you to avoid , uh , foods high in sugar . um , and the , the nurse will come in and she'll give you a glucometer and teach you how to do blood sugar testing . okay ?
[patient] okay .
[doctor] and then , from an atrial fibrillation standpoint , your heart , even though you're in atrial fibrillation right now , is in a good rate . and we'll just continue you on your metoprolol , 25 milligrams , twice a day . do you need a refill on that ?
[patient] yes , i do .
[doctor] hey , Sarah ? order a refill on metoprolol , 25 milligrams , twice a day . and for your reflux , we'll just continue you on the protonix , okay ?
[patient] okay .
[doctor] do you have any questions , hannah ?
[patient] no , not at this time .
[doctor] okay , so the nurse will come in and she'll go over all that stuff with you .
[patient] okay .
[doctor] take care .
[patient] thank you .
[doctor] hey , Sarah ? finalize the note .
| CHIEF COMPLAINT
Evaluation of high blood sugar.
HISTORY OF PRESENT ILLNESS
Ms. Hannah Phillips is a 52-year-old female who presents for evaluation of high blood sugar. The patient admits to dietary indiscretion. She notes that she has been eating more sweets during the holidays. She reports that this past week, she felt really lightheaded, was seeing spots in her vision, and was really dizzy. She went to the emergency room and was told that she had high blood sugar. Ms. Phillips was given IV fluids. The patient was also instructed to get into a routine and watch her diet. She states that she is staying with family during the holidays and having trouble returning to her routine diet, but wants to make sure that her high blood sugar is not an issue.
The patient denies any fever or chills. She denies chest pain or shortness of breath. She denies abdominal pain or burning when she urinates. She denies joint pain or muscle aches.
She notes that she has osteoarthritis, and that nothing seems out of the ordinary for her joint pain.
The patient has a history of atrial fibrillation. She states that she has felt her heart racing when she is anxious; however, other than that, she has not experienced any issues. She is currently taking metoprolol 25 mg 2 times per day.
Regarding her acid reflux, she states that she has been doing well. She has been taking the medication that was prescribed to her, and it has been very helpful. She is on the Protonix 40 mg once daily, and she is doing well with that
REVIEW OF SYSTEMS
• Constitutional: Negative for fever, chills
• Cardiovascular: Negative for chest pain
• Respiratory: Negative for shortness of breath.
• Gastrointestinal: Negative for abdominal pain.
• Genitourinary: No dysuria.
• Musculoskeletal: No Arthralgias, Myalgias.
PHYSICAL EXAMINATION
Constitutional
• General Appearance: appear in no distress.
Neck
• General Examination: Her thyroid is a little enlarged but nontender. There are no carotid bruits. Respiratory
• Auscultation of Lungs: Clear bilaterally. Cardiovascular
• Auscultation of Heart: Irregular rate and rhythm. Musculoskeletal
• Examination of Abdomen: Nice soft and have no edema in lower extremities.
RESULTS
Glucose: elevated.
HbA1c: elevated.
ASSESSMENT AND PLAN
Ms. Hannah Phillips is a 52-year-old female who presents for evaluation of high blood sugar.
Diabetes.
• Medical Reasoning: Elevated blood glucose and hemoglobin A1c levels based on recent labs.
• Additional Testing: We will order a complete metabolic panel for further evaluation.
• Medical Treatment: Initiate metformin 500 mg twice daily. Encouraged dietary modifications. The patient will be given a glucometer to monitor her glucose levels at home.
Atrial Fibrillation.
• Medical Reasoning: Asymptomatic and well-controlled at this time.
• Medical Treatment: Continue metoprolol 25 mg twice daily. Refilled today.
History of Reflux.
• Medical Reasoning: Well-controlled on current regimen.
• Medical Treatment: Continue Protonix 40 mg daily.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N136 | virtassist | [doctor] hi janet , how are you ?
[patient] good , how are you ?
[doctor] i'm good . uh , are you ready to get started ?
[patient] yes .
[doctor] okay . so , janet is a 33-year-old female , here for some , some joint paint . what , what joint's been bothering you , janet ?
[patient] it's been mostly , um , my knees , actually . i've been doing more stair type workouts , which i thought was , you know , building muscle , uh , on my knees and supposed to help .
[doctor] mm-hmm .
[patient] but in turn it , it really has n't , so my knees have been really bothering me .
[doctor] okay . all right . and is it one knee versus the other ? or both equally ?
[patient] it's both equally .
[doctor] okay . and have you been having any other joint pain like , elbows or shoulder , or anything like that ?
[patient] no , but i , i should mention that like , i had a rotator cuff repair about two years ago .
[doctor] mm-hmm .
[patient] um , but i have n't had any problems since that point .
[doctor] okay , and what shoulder was that ?
[patient] that was my right shoulder .
[doctor] okay , all right . and , um , any pins and needles in your feet at all ? any swelling in your legs ?
[patient] uh , no , nothing like that .
[doctor] okay .
[patient] um , but it would be something though i look out for often , just because i have diabetes .
[doctor] okay , and your blood sugars have been under control ?
[patient] yes , they have been .
[doctor] okay . and have you had any fever or chills ?
[patient] no , nothing like that .
[doctor] okay . any nausea or vomiting , chest pains , shortness of breath ?
[patient] no , but i do have high blood pressure , um , but i , i monitor that and i've been taking medication for that , and that has n't elevated , um , in any way since the joint pain .
[doctor] okay . all right . so , yeah , i see on here that you do take norvasc , five mg a day and you've been taking that every day-
[patient] yes .
[doctor] okay . um , and , um , so let's go ahead and do a quick physical exam on you . so , hey Sarah , show me the blood pressure . your blood pressure's actually pretty high today , so you might be a little nervous here , which is not uncommon .
[patient] yeah .
[doctor] um , so , looking at you , your , your neck is nice and soft , there's no enlarged thyroid . your heart has a regular rate and rhythm . your lungs are clear . your abdomen is nice and soft , but looking at your knees , on your left knee you do have a slight erythema and edema . there is a small efusion present over your left knee . um , you have some decrease flexion and extension of your knee , but your strength in your lower extremities is good . uh , so let's go ahead and look at some of your results . i know that we did some x-rays when you came in .
[patient] yeah .
[doctor] hey Sarah , show me the left knee x-ray . okay , so looking at this , this is an , this is a normal x-ray of your left knee , so you may just have a little bit of a strain going on in your , in your knees there .
[patient] okay .
[doctor] uh , let's look at some of your labs , 'cause i know that you have the diabetes . hey Sarah , show me the labs . so , here your white blood cell count is not elevated , so i'm not concerned about an infection or anything like that . um , hey Sarah , show me the diabetes' labs . okay and , and your a1c is a little elevated , but it's not , it's not terrible , so i think for right now we'll just continue you on the current regimen . um , so my plan from you , for you in terms of the joint pain , um , i'd like to go ahead and , you know , we'll just send some autoimmune labs to work , work up your left knee pain and , uh , we'll work for you to do some physical therapy and i'd like to go ahead and give you anti-inflammatory medication to help with the pain . does that sound okay ?
[patient] that sounds great .
[doctor] okay . hey Sarah , order meloxicam 15 mg once a day . hey Sarah , order a physical therapy referral . hey Sarah , order an autoimmune profile . and then from a hypertension standpoint you , because your blood pressure is a little elevated today , i'd like you to continue to monitor it at home and , you know , send me a report in the next couple of weeks sh- , you know , giving me the , the blood pressure reportings . do you have a blood pressure cuff at home ?
[patient] yes , i do .
[doctor] okay . and then , um , we'll go ahead and order a lipid profile for you . hey Sarah , order a lipid profile . and then for , from a diabetes standpoint let's go ahead and , uh , continue you on your metformin 500 mg twice a day . okay ?
[patient] okay .
[doctor] do you have any questions ?
[patient] no , that's it .
[doctor] okay . the nurse will be in soon . it was good to see you .
[patient] nice seeing you too .
[doctor] hey Sarah , finalize the note .
| CHIEF COMPLAINT
Joint pain.
HISTORY OF PRESENT ILLNESS
Ms. Janet Sullivan is a 33-year-old female who presents to the clinic today for evaluation of joint pain.
She localizes the joint pain to her bilateral knees. The patient reports she has been doing stair workouts, which she thought was building muscle on her knees. She denies any pins and needles in her feet or swelling in her legs. The patient notes that she would look out for those symptoms because she has diabetes. She denies any fever or chills. She denies any nausea or vomiting. The patient denies any chest pain or shortness of breath.
She notes she had a right shoulder rotator cuff repair about 2 years ago, but she has not had any problems since that point.
She reports that her diabetes are well-controlled.
The patient does have high blood pressure but she monitors it and takes Norvasc 5 mg a day. She notes her blood pressure has not been elevated since her joint pain started.
REVIEW OF SYSTEMS
• Constitutional: Negative for fever, chills
• Cardiovascular: Negative for chest pain or lower leg swelling.
• Respiratory: Negative for shortness of breath.
• Gastrointestinal: Negative for nausea, vomiting.
• Musculoskeletal: Positive for Arthralgias
PHYSICAL EXAMINATION
Neck
• General Examination: Neck is supple without thyromegaly.
Respiratory
• Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.
Cardiovascular
• Auscultation of Heart: Regular rate and rhythm.
Musculoskeletal
• Left knee: Slight erythema and edema. Small effusion present. Decreased flexion and extension. Strength in lower extremities is good.
RESULTS
Views: Four views left knee.
Indication: Knee pain.
Interpretation: There are no fractures, dislocations, or other abnormalities.
PLAN
Ms. Janet Sullivan is a 33-year-old female who presents to the clinic today for evaluation of joint pain.
Left knee strain.
• Medical Treatment: We will order an autoimmune panel for further workup. I am going to refer her to physical therapy and prescribe meloxicam 15 mg once daily to help with pain.
• Specialist Referrals: Physical therapy.
Hypertension.
• Medical Reasoning: Her blood pressure is elevated in office today, but has been well-controlled on Norvasc 5 mg daily based on home monitoring.
• Medical Treatment: Continue current regimen and home monitoring. She will send me a report in the next couple of weeks. We will also order a lipid profile.
Diabetes type II.
• Medical Reasoning: Her hemoglobin a1C is slightly elevated, but her blood glucose levels have been well-controlled.
• Medical Treatment: Continue metformin 500 mg twice a day.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N137 | virtassist | [doctor] morning christine , nice to see you .
[patient] nice to see you too .
[doctor] so i know my nurse told you a little bit of- ... um , about dax and i'm gon na tell dax a little bit about you , if that's okay ?
[patient] go for it .
[doctor] okay , great . um , uh , this is christine . she's a 63-year-old female patient . you're here for your routine , um , yearly exam . um , i know you have a history of high blood pressure and you've had some depression in the past . and i also know you did have a carpal tunnel release done about two years ago . um , how have you been doing ?
[patient] i've been doing well . um , the depression standpoint is doing great . i've been using , um , the medication you prescribed me last time and going to therapy every week . and that's really helped me manage .
[doctor] okay . and you're sleeping well at night ? and everything's been going well from that standpoint ?
[patient] yeah , i've been getting a full eight hours .
[doctor] okay . and no thoughts of hurting yourself or anything like that ?
[patient] no .
[doctor] okay , good . um , and , um , i- i know you've had some high blood pressure in the past . have you been checking your blood pressure ?
[patient] i have . it's been a little bit up and down-
[doctor] okay .
[patient] lately , i have n't had a normal , um , normal reading- reading in a couple of weeks . um , it's either been high or low . um , has n't really stayed put .
[doctor] has n't really stayed put ?
[patient] yeah .
[doctor] okay . and , um , you've been talking your medication though , right ?
[patient] yes , i have .
[doctor] okay .
[patient] my diet's been a little all over the place . i have been really stressed with work and putting in more hours, so you know, it has been hard. i have not had time to go to the grocery store, let alone prepare and cook meals. so, i have been eating a lot of frozen meals.
[doctor] okay .
[patient] that type of thing .
[doctor] and have you had any headaches or swelling or anything like that that's been abnormal ?
[patient] i have some headaches but i just thought that was looking at a computer screen all day .
[doctor] okay , well , that's fair .
[patient] yeah , exactly .
[doctor] okay good . and , um ... i know my nurse did a review of systems . other than what we've just talked about , has there been anything else that you wanted to add to that ?
[patient] um , my carpal tunnel release has been doing well . on , uh , we did that , i think it was two years ago now .
[doctor] okay .
[patient] uh , on my right , um , wrist , and that's been great .
[doctor] great , great . no numbness or tingling in your hands ?
[patient] no .
[doctor] fingers ? okay , good . all right , well , um , lem me do a quick exam if that's okay ?
[patient] okay .
[doctor] deep breath . squeeze my fingers for me . feel me touch you here ?
[patient] yup .
[doctor] can you touch down here ?
[patient] mm-hmm .
[doctor] can you push your leg out ? push this one up . pull it back . yeah , good . okay . so on my exam , um ... your exam's essentially normal , your lungs are clear , are- ... you do n't have any adenopathy in your neck , you do n't have any , um , uh , hyperthyroidism . um , your heart is regular without any murmurs . um , your grips are equal , neurologically intact , strength is good , pulses are good . so overall , um , your exam is fine . let's take a- a look at some of your labs and vital signs .
[patient] okay .
[doctor] hey Sarah , show me the blood pressure . okay , so here in the office today it is a little bit elevated , okay ? so your blood pressure is a little bit high . so the results , um , do show that . um , hey Sarah , show me the labs . okay , so good news is is your- your labs are all essentially normal , so the results of your labs are essentially normal , okay ? so ... um , my assessment is that your- ... you do have hypertension still . um , and i think we need to increase your blood pressure medicine a little bit , okay ? so i'm gon na increase your lisinopril to 10 milligrams a day , just once a day , um , but i'm gon na increase that a little bit , okay ? and then want you to check it and i'm gon na have you come back in a month and we'll see how you're doing with regards to that , okay ?
[patient] okay .
[doctor] um , your second problem is your dep- depression , you're doing great , i do n't wan na change anything at this point . let's just stay- ... we'll change one thing with your high blood pressure-
[patient] mm-hmm .
[doctor] so i do n't wan na change any other medications at this point in time , so let's just leave that as it is .
[patient] okay .
[doctor] and then your third problem was your carpal tunnel . that seems to be doing well . if you notice any tingling or any changes or you get some of those symptoms back , just let me know . okay ?
[patient] okay .
[doctor] all right . anything else i can do for you today ?
[patient] no , that's it .
[doctor] okay . great . uh , lem me get you checked out .
[patient] okay .
[doctor] hey Sarah , finalize the report .
| CHIEF COMPLAINT
Annual exam.
HISTORY OF PRESENT ILLNESS
Christine Flores is a 63-year-old female presenting for her yearly exam. She has a history of high blood pressure and depression in the past. She also had a right carpal tunnel release done about 2 years ago.
The patient states that she has been doing well with her depression. She notes that she has been taking her medication as prescribed at her last visit. She states that she has been going to therapy every week, which has helped her manage her symptoms. The patient notes that she is sleeping well at night and has been getting a full 8 hours. She denies any thoughts of self-harm or harming others.
The patient states that she has been checking her blood pressure at home. She notes that her blood pressure has fluctuated lately. She states that she has not had a normal reading in a couple of weeks. The patient has continued utilizing her medications.
She states that her diet has been a little all over the place. The patient notes that she has been working more hours. She reports that she has had some headaches, however, she thought that it was related to her increased screen time.
The patient states that her right carpal tunnel release has been doing well. She denies numbness or tingling in her hands or fingers.
REVIEW OF SYSTEMS
• Cardiovascular: Endorses blood pressure issues.
• Neurological: Endorses headaches.
• Psychiatric: Endorses depression.
PHYSICAL EXAMINATION
• Neurological/Psychological: Appropriate mood and affect. Bilateral grip strength equal. Neurologically intact.
• Neck: Supple without thyromegaly or cervical lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.
VITALS REVIEWED
• Blood Pressure: Elevated.
RESULTS
Laboratory studies are all within normal limits.
ASSESSMENT AND PLAN
Christine Flores is a 63-year-old female presenting for her yearly exam.
Depression.
• Medical Reasoning: She is doing well and managing this with medication and weekly therapy.
• Medical Treatment: Continue current regimen.
Hypertension.
• Medical Reasoning: Her blood pressures have been fluctuating lately. She does admit to dietary indiscretion due to her increased workload.
• Medical Treatment: Increase lisinopril to 10 mg once daily.
• Patient Education and Counseling: She should continue to monitor this at home and follow up in 1 month.
Carpal tunnel release.
• Medical Reasoning: She is doing well 2 years postoperatively and is asymptomatic at this time.
• Patient Education and Counseling: She will contact us if her symptoms return.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N138 | virtscribe | [doctor] next patient is emily hernandez . date of birth , march 26 2001 . this is a 20 year old female being seen today for our yearly follow-up for asthma , allergic rhinitis and food allergy . due to insurance changes since our last office appointment in april 2020 , she was switched from symbicort to wixela . she also uses zyrtec in the spring , summer and fall for her seasonal allergy symptoms , which tend to work well . she also has known peanut allergy , she does tolerate almonds and cashews . please put in the asthma section at the very bottom that the act score is 21 . please put under interval history , written consent is obtained today to use dax for documentation .
[doctor] hi emily , how are you ?
[patient] i'm pretty good , how are you ?
[doctor] i'm good , thank you . so gosh , we last talked a little bit over a year ago and it was just a telemedicine visit , but it seems like you've been doing pretty good . i know there was an insurance change . i think you had switched over to wixela , is that right ?
[patient] yep , that's right , and it's what i'm currently using .
[doctor] okay , and that's the 250/50 dose , correct ?
[patient] yes , correct .
[doctor] perfect . so how does that compare ?
[patient] i mean , it's working well . i really have n't had any issues with it and i take it once in the morning and once at night .
[doctor] and that's one puff twice a day ?
[patient] mm-hmm .
[doctor] okay . and have you been having to use your albuterol inhaler at all ?
[patient] rarely , and if i do it's really just before a workout or something out that , if i know i'm really going to be pushing it .
[doctor] so it sounds like it's around strenuous activity .
[patient] yes .
[doctor] okay . so you can do things like go on a walk or going to the grocery store no problem , and just use it for more exertional stuff ?
[patient] yes . like , if i'm gon na go for a run or something like that i'll really just take it before as a preventative .
[doctor] okay .
[patient] and i've been trying to use my daily if i can a little less because i'm trying to go into the military soon .
[doctor] no kidding , that's great .
[patient] yeah , so i have to be able to operate basically at a certain fitness level without an inhaler .
[doctor] really ?
[patient] yeah , and if i can prove that i'm capable of these activities without an inhaler it makes it easier .
[doctor] and so by inhaler do they mean both your daily and rescue inhalers ?
[patient] mm-hmm . so it's like they'll have a fitness test and basically they'll tell me not to take my inhaler that day before the test , and then they'll see how the asthma affects me . and they're looking to see if it's serious enough to hold me back from joining or whatever . so i have been taking it less and less . and really some days i feel like i do n't need it .
[doctor] and that is the wixela that you're not taking . so on average per week , how many days of the week do you use one puff in the morning and one puff at night ?
[patient] probably about three or four .
[doctor] okay , three to four days per week and the other days it's once a day ?
[patient] yes , that's correct .
[doctor] okay .
[patient] and it's either in the morning or at night that i'm taking it .
[doctor] okay , and do you think that's working okay ?
[patient] i do .
[doctor] great . and any urgent care or er visits at all for breathing over the past year ?
[patient] nope .
[doctor] okay , so i'm going to assume no one has put you on prednisone for breathing issues then .
[patient] nope .
[doctor] okay . and now , military wise , what's the time frame of when you'll be completing some of these exertional tests ? like , what are your next steps ?
[patient] so , hopefully i'm going to be enlisted early spring of 2022 . so that gives me about six to seven months to get to a point where i'm able to exert my body where i do n't really need the inhaler . or at least show them that i have it under control .
[doctor] now when you were in the other room you completed a breathing test , correct ?
[patient] correct .
[doctor] okay , great . so now let me ask you about the allergies , 'cause i know typically you'll use the zyrtec in the spring , summer and fall , correct ?
[patient] yeah , i do n't really ... um , or i'm sorry , i use it more during the spring and fall . i do n't really have to use it too much in the summer .
[doctor] do you use it more just as needed in the summer ?
[patient] yeah , that's right .
[doctor] okay . and have you been taking the zyrtec every day recently since you're right in the mix of spring ?
[patient] not every day , but i do take it on days i know i'm going to be outside a lot . um , i do tend to work outside about three days a week so i'll definitely take it on those days .
[doctor] and does it seem to work pretty well still ? are you happy with it ?
[patient] yeah , it does , it works great .
[doctor] wonderful , good to hear . and then i'm assuming you're staying away from the peanuts . uh , last year you had told me it worked with ... uh , you worked with enterprise rent-a-car and one of the cars had a lot of peanuts in it that you were cleaning out and that gave you hives , uh , when you had touched it , is that correct ?
[patient] yep , that's correct .
[doctor] okay . and has there been anything like that since that experience ?
[patient] no , i do n't think so . i definitely became more cautious after that , so i usually wear , uh , wear long sleeves and change my gloves every time now . so i have n't had a reaction , but i imagine that i probably came into contact with cars that had peanuts in them , but they just d- did n't touch my skin .
[doctor] super . and it sounds like you're really smart about it .
[patient] yeah , and the airplanes , they have peanuts . they give everyone too , so .
[doctor] okay . and you have an epipen that k- that you keep with you , correct ?
[patient] yes .
[doctor] okay . and i'm assuming you're going to need refills , um , i can call you in a new set for the year . typically of course , they expire within a year .
[patient] yeah , okay .
[doctor] and i remember , um , sometime previously you've had some testing for tree nuts , but you do have almonds and cashews , correct ? and- and you do okay with them , or do you avoid all tree nuts ?
[patient] i do tend to avoid all of them but i recall eating some almonds at one point , uh , really soon after we discussed i might not be allergic to tree nuts anymore .
[doctor] okay .
[patient] and i remember having them and nothing happened , but i usually just tend to stay away from them , um , really if i can help it .
[doctor] okay . so sometimes when people have a peanut allergy , the nuts in general just are n't very important to them , so it is very common to avoid both . um , so let's do this . i'll have helen come in and i would love to complete a breathing test on you . if your breathing numbers are looking great we can work on getting you , uh , something lower than wixela . if you look at all of our asthma regimens it is a stepwise process , and wixela is a combination of two medications in one . and , well maybe you do n't need both of'em . uh , maybe you just need one of'em . so we can work our way backwards .
[patient] okay .
[doctor] and so the breathing test will help give us some- some more guidance , we will look at the results in just a moment .
[patient] all right , and so this past year i did get into the bad habit of vaping and smoking , but i have been trying to cut that out . so i should be good , and , um , now i only do just a little bit and i am trying to quit . so i am sure that might have an effect .
[doctor] it can . um , so what we can do today is compare your results with prior results , probably before you started smoking or using the vape .
[patient] okay .
[doctor] yeah . and we'll see where you stand at that point .
[patient] all right , that sounds good .
[doctor] well let me go ahead and listen , so hop on up here for me .
[patient] okay .
[doctor] all right so your ears look good , a little bit of wax on both sides . can i see inside your mouth ? big ahh .
[patient] ahh .
[doctor] good . okay let me take a peek in your nose . all right , good . you can put your mask back on .
[patient] okay .
[doctor] and go ahead take a big breath in and out . good , your lungs sound terrific . i'll listen to your heart , breathe quietly . okay very good .
[patient] awesome .
[doctor] so your breathing test is about the same as it was a couple years ago , and actually looks a little bit better . you may not remember but when we last completed the test in 2019 , uh , do you recall if you were feeling lousy at the time ?
[patient] i think it was the smoke . there were so many fires at that point and i remember coming in and looking out the window and all you saw was the orange and the smoke .
[doctor] yes , you're absolutely right , that was a bad year . that was my first fall here and i was really alarmed . well that explains why at that time your numbers were a little bit lower and today they look better . here's what i think , so you'll have kaiser currently , correct ?
[patient] correct .
[doctor] okay . most insurances do limit what we can use .
[patient] yeah i do know that .
[doctor] okay so option one would be to continue using wixela like you're using it now . we would classify it as off-label and you can use it once a day instead of twice a day , which is fine . some people do that because they just need it once a day , so that's an option . option two would be to actually back up to an inhaler that just has one med .
[patient] mm-hmm
[doctor] so the one that kaiser covers is alvesco . the thing about alvesco , though , is that it would be two puffs in the morning and two puffs at night . so it's a bit more work . um , it's not breath activated but we could step down the lowest dose to see how you do . some of the newer guidelines for asthma that were published this year is recommending trying to treat people with inhalers like wixela or alvesco only when you're ill , or say during smoke season . so minimizing their use to those periods of time versus all year . unless you found out that you're getting
[ inaudible 00:09:25 ] sick having issues every month , then that would indicate would pull back too much .
[patient] okay .
[doctor] that we had too much , yeah .
[patient] okay .
[doctor] um , so we could step back and possibly get you to the point where you just use those inhalers , uh , when you're ill or it's smoke season , but at the first step to do any of that would be to try to drop down to just alvesco .
[patient] okay , that actually sounds really good .
[doctor] okay great . so i will call that in for you , it will be the lower dose , 80 mcg , and you'll have to do two puffs twice a day .
[patient] all right
[doctor] okay and that'll be on the box when i call it in . you can put the wixela off to the side , but do n't throw it away just in case the alvesco does n't work well for you .
[patient] okay , got it .
[doctor] and then ideally we would repeat your breathing test in four months to see how you're doing , and then be able to document that you're doing well . sometimes , not always , the military will require documentation on breathing tests .
[patient] okay .
[doctor] is your pharmacy still the same or did you update it with helen ?
[patient] yeah i believe she updated it . it should be kaiser permanente broadway .
[doctor] okay perfect . i'll make sure it's the alvesco and then i'll renew your albuterol and epipen as well .
[patient] awesome , thank you .
[doctor] you're welcome . uh , then the zyrtec , do you pick it up over the counter or do get- do you get it as a prescription ?
[patient] i just get it over the counter .
[doctor] okay got it . and do you have a nebulizer that you would , uh , need refills on ?
[patient] i do n't think i need any refills , i have n't used that in such a long time . i think the last time was when i had bronchitis , or there was few select times when i had to use it when i was kid .
[doctor] okay good . well i think we have our game plan .
[patient] okay awesome .
[doctor] and do the alvesco two puffs twice a day and your albuterol if you need it . the zyrtec 10 milligrams as you need it and continue to stay away from peanuts and tree nuts and i'll refill your epipen .
[patient] okay
[doctor] all right so we've got it .
[patient] great .
[doctor] all right i'll have you take this to the front and i'm gon na say four months re-check for asthma and we'll repeat the spirometer- spirometry at that time .
[patient] okay sounds good .
[doctor] all right well thanks so much and you have a great day .
[patient] you too .
[doctor] and we'll do a follow-up in four months with act and spirometry , sooner if needed . follow-up 25 minutes . | CHIEF COMPLAINT
Follow-up for asthma, allergic rhinitis, and food allergy.
HISTORY OF PRESENT ILLNESS
Emily Hernandez is a 20-year-old female presenting today for an annual follow-up for asthma, allergic rhinitis, and food allergy. Due to insurance changes during the interim of our last office appointment from 04/2020, she was switched from Symbicort to Wixela. She uses Zyrtec in the spring, summer, and fall for her seasonal allergy symptoms, which tends to work well. She has known peanut and tree nut allergies, which she tries to avoid. She does tolerate almonds and cashew.
Mrs. Hernandez is trying to join the military, who require a certain fitness level without use of a rescue or maintenance inhaler, so she has been weaning off her inhalers. She uses albuterol prior to a run, but otherwise functions without it. She has been reducing her Wixela dose, using 1 inhalation once daily 3 times per week, with remaining days using it twice per day as prescribed. She feels this is working well. She denies urgent care or emergency room visits for respiratory issues in the past year. She denies requiring prednisone for breathing issues in the past year.
She hopes to be enlisted in the military in early spring of 2022. She is currently undergoing exertional testing to this purpose. She explains that this gives hers 6 to 7 months to show that she can exert herself without needing any inhalers.
Over the past year, she admits to vaping and smoking, though she is trying to quit and has cut down her use significantly.
She notes having a nebulizer but denies needing it recently and has only used it in her past for upper respiratory infections and as a child a few times.
Mrs. Hernandez uses Zyrtec during the spring and fall but does not typically have to use it consistently during the summer. She confirms she has been taking Zyrtec 3 days per week when she works outside, and it works well to control her symptoms.
She has been successfully avoiding peanuts. Incident from last year was reviewed where she was exposed to peanuts when she was cleaning an Enterprise rental car that had a lot of peanuts in it. She developed contact hives when the peanuts encountered her skin. Over the past year she denies additional accidental exposures. She wears long sleeves and changes her gloves between each cleaning. She thinks it is likely that she has been in contact with cars that contained peanuts, but due to her protective measures she did not touch them directly. She confirmed she always keeps an EpiPen with her.
The patient is also avoiding tree nuts. She did ingest almonds without issue following our discussion that she could try them. Despite tolerating them well, she continues to avoid all tree nuts.
PAST HISTORY
Medical
Asthma.
Allergy rhinitis.
Food allergies to peanut and tree nuts.
SOCIAL HISTORY
Currently smokes tobacco and vapes, trying to reduce and interested in cessation in preparation for joining the army.
CURRENT MEDICATIONS
Wixela Inhub 250 mcg-50 mcg/dose powder for inhalation. 1 puff 2 times daily in the morning and evening.
Proair HFA as needed.
EpiPen as needed.
Alvesco 80 mcg 2 puff 2 times daily.
ALLERGIES
Peanuts cause a severe, anaphylactic reaction.
Montelukast sodium, “seizure-like” reaction.
RESULTS
Asthma Control Test (ACT) Results: ACT score is 21.
Current food skin test sensitivities include peanuts.
ASSESSMENT
• Moderate persistent asthma, uncomplicated.
• Allergic rhinitis.
• Anaphylactic reaction due to peanuts.
Emily Hernandez is a 20-year-old female who presented today for her yearly follow-up appointment for asthma, allergic rhinitis, and food allergy.
PLAN
Moderate persistent asthma, uncomplicated
The patient has been using Wixela inhaler daily and admits to reducing her daily dose to one puff per day, 3-4 days per week as she feels she does not always need it the full dose. Additionally, she aspires to join the military and she must meet certain physical fitness requirements without the use of her inhaler. I counseled the patient on current asthma treatment guidelines which recommend using Wixela and Alvesco only when needed during periods of illness. The patient agreed to reducing her medicine to Alvesco which is a single medication, versus 2 in Welixa. The patient will continue to use her albuterol inhaler as needed. Her ACT score is 21 today and her spirometry test today was better than it was in 2019, though she recalls that it was smoky from wildfires during her last breathing test.
Allergic rhinitis
She will continue to use Zyrtec as needed, primarily during spring and fall and sometimes in summer. Her current dose cadence is 3 times per week when she works outside. Symptoms are currently under control.
Anaphylactic reaction due to peanuts
The patient has successfully avoided peanuts. Plan is to continue with current methods to avoid exposure. I will refill her EpiPen which expires annually.
INSTRUCTIONS
Moderate persistent asthma, uncomplicated
Start Alvesco, 2 puffs twice daily. Keep Wixela in case Alvesco does not work well. Continue albuterol as needed. Return in 4 months to repeat ACT and spirometry testing.
Allergic rhinitis
Continue Zyrtec 10 mg daily as needed.
Anaphylactic reaction due to peanuts
Continue strict avoidance of peanuts. I will refill her EpiPen today. |
D2N139 | virtscribe | [doctor] all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 .
[doctor] hello mr. roberts , how are you doing today ?
[patient] i'm fine , thank you .
[doctor] good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations .
[patient] yeah . that was back in march i think , but my girlfriend and i , we talked about it , and on that day i had a few cups of coffee , and no breakfast . so , i think it was probably more of a panic attack than anything else .
[doctor] yeah . have you , uh , have you felt it again since ?
[patient] uh , no .
[doctor] okay . uh , so tell me about the blood pressure then .
[patient] well , i've had issues with my blood pressure since i was young .
[doctor] do you have a family history of this ?
[patient] yeah . a lot of my family does have high blood pressure .
[doctor] i see .
[patient] yeah , i thought it was getting better , and , uh , i have a new primary doctor , and she put me on a new medication about a month ago .
[doctor] uh , can you tell me which medications you're taking ?
[patient] my new med is , uh , a combo med , something 40-25 .
[doctor] okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it .
[patient] yeah , that's it . my water pill i call it .
[doctor] okay . are you still taking the amlodipine , 10 milligrams daily ?
[patient] uh , yes i am .
[doctor] that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ?
[patient] um , every day .
[doctor] awesome .
[patient] yeah . every morning , i take it when i get up , and it's been running at about , uh , 146 to 155 lately .
[doctor] so you're not down in the 120s yet ?
[patient] no , not yet . well , we're trying to get there though .
[doctor] okay . uh , how are you doing with your salt intake ?
[patient] i'm trying to back off of it . i think i'm doing good with it , not eating too much .
[doctor] good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure .
[patient] sounds good .
[doctor] are you doing any exercise ?
[patient] i do try to walk on the treadmill when i can .
[doctor] okay , great . um , all right . so , let's take a look .
[patient] all right .
[doctor] uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .
[patient] okay .
[doctor] so , use my general physical exam template . let me take a listen to you and make sure everything sounds good .
[patient] all right .
[doctor] your heart and lungs sound good , so that's great .
[patient] good to hear .
[doctor] all right . go ahead and lie down . uh , and let me know if anywhere i press hurts .
[patient] nope . nowhere .
[doctor] all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling .
[patient] all right .
[doctor] all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ?
[patient] uh , no .
[doctor] okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone .
[patient] okay . so , is there something we can do about it ?
[doctor] um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try .
[patient] all right . i mean , i'm willing to give it a try .
[doctor] okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room .
[patient] all right . i guess that makes me feel a little bit better .
[doctor] yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay .
[patient] all right . no , that i can do . um , are there any other side effects i need to worry about ?
[doctor] uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon .
[patient] i'll definitely let you know if that happens .
[doctor] okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure .
[patient] i understand .
[doctor] yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure .
[patient] okay .
[doctor] um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure .
[patient] really ? i did n't realize that .
[doctor] yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff .
[patient] okay . i'll definitely check that out .
[doctor] all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic .
[patient] all right .
[doctor] all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure .
[patient] that's interesting .
[doctor] yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication .
[patient] sounds good to me .
[doctor] all right . so , we will see you in two weeks then .
[patient] sounds good . thanks doc .
[doctor] yeah , you're welcome . let me know if you have any questions .
[patient] will do .
[doctor] all right . have a great day mr. roberts .
[patient] you too .
[doctor] mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic . | CHIEF COMPLAINT
High blood pressure and palpitations.
HISTORY OF PRESENT ILLNESS
Jordan Roberts is a 49-year-old with a long history of hypertension and an acute episode of palpitations.
In March, Mr. Roberts went to the emergency room for palpitations and hypertension. He attributed this to a panic attack, but also stated he consumed several cups of coffee on an empty stomach the morning of. He denies additional episodes of palpitations.
He has been monitoring his blood pressure at home daily, obtaining systolic blood pressure readings of 146 to 155. He does report a family history of hypertension. Additionally, he has been monitoring his salt intake and feels he is doing well at reducing it. He also walks on his treadmill as often as he can.
He has a new primary care physician who started him on a new medication Benicar HCT, which he has been using for the past month.
PAST HISTORY
Medical
Hypertension.
FAMILY HISTORY
Several family members positive for hypertension.
CURRENT MEDICATIONS
Benicar HCT 40 mg/25 mg
Amlodipine 10 mg daily.
Physical Examination
Cardiovascular
Normal rate, regular rhythm, S2 normal, normal heart sounds, and normal pulses.
Pulmonary/Chest
Breath sounds normal.
Abdominal
There is no tenderness.
Musculoskeletal
There is no edema.
RESULTS
Thyroid profile 03/01/2021.
ASSESSMENT
• Resistant hypertension.
Mr. Roberts presents with resistant hypertension, with systolic blood pressure readings between 146-155. He is currently on maximal doses for 3 medications.
PLAN
I have added spironolactone to his regimen which will require monitoring of his potassium and sodium. We will schedule him for a follow up in 2 weeks to complete a basic metabolic panel and check his blood pressure. Next medication to consider adding is carvedilol. I have tried to avoid this, given the potential for issues with erectile dysfunction. I counseled the patient about spironolactone side effects, including gynecomastia and electrolyte disturbances, as well as his increased risk of dehydration, with one sign to watch for being dizziness. If we are not able to improve his blood pressure with spironolactone, the next step would be sending him to the resistant hypertension clinic.
I provided and reviewed with Mr. Roberts the American Heart association website (heart.org) and encouraged him to access for tips on lowering his salt intake and increasing his potassium intake. His maximum salt intake should be 1500 to <2000 mg per day. He was provided materials to follow the DASH diet and encouraged to meet 30-min of walking most days.
INSTRUCTIONS
Schedule follow up appointment in 2 weeks for blood pressure check and basic metabolic panel. Reduce sodium intake to 1500 to <2000 mg per day. Follow DASH diet.
|
D2N140 | virtscribe | [doctor] brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl .
[doctor] she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started .
[doctor] hello , how are you ?
[patient] i'm okay .
[doctor] good . how have you been feeling ?
[patient] not so good .
[doctor] yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp .
[patient] yeah , i have .
[doctor] okay . well , your gut probably does not always appreciate that .
[patient] no , it does n't like it at all .
[doctor] yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea .
[patient] i've been getting both .
[doctor] okay . um , so how frequently have you been getting or having a bowel movement on normal days ?
[patient] i'm starting to notice it's between two and three times a day .
[doctor] okay . and are they soft stools or formed stools ?
[patient] um , they're formed .
[doctor] okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ?
[patient] yeah , i do .
[doctor] okay . do you feel it's the food or the alcohol or both ?
[patient] uh , well usually we go to friday's restaurant . i always eat pasta , the chicken alfredo .
[doctor] okay . i can s- i can bet it's the alfredo sauce .
[patient] but it normally does n't bother me .
[doctor] okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ?
[patient] no .
[doctor] okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ?
[patient] most of the time it's either tequila or dark liquor . i prefer patron , but if i get brown liquor , i only get two . um , every now and again , i'll drink a martini .
[doctor] sometimes it's the mixer they tend to put in the drinks , but it can be a variety of things . um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ?
[patient] um , no . i guess i need to find a new drink .
[doctor] okay . and how is it during the week ?
[patient] like what i eat ?
[doctor] yeah , and with the diarrhea and abdomal- um , abdominal pain .
[patient] right now , i'm still having the cramping and sharp pains , so i've been avoiding heavy foods . i did have some fried chicken today , though .
[doctor] and was everything all right after that ?
[patient] yeah , for the most part .
[doctor] okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions .
[patient] okay , good . i ca n't go out- go without some fried chicken at least once in a while .
[doctor] sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam .
[patient] sounds good .
[doctor] all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen .
[patient] okay .
[doctor] all right . do you have any tenderness ?
[patient] no , not really .
[doctor] okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you .
[doctor] all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine .
[patient] okay , that sounds good .
[doctor] okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose .
[patient] can i get a refill of that ?
[doctor] yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse .
[patient] yeah , i noticed i've been doing better with drinking water instead of sodas .
[doctor] okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water .
[patient] okay .
[doctor] okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks .
[patient] okay , i can do that .
[doctor] okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ?
[patient] i was actually going to ask you about something like that to help avoid flares altogether .
[doctor] yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ?
[patient] that sounds like a much better plan .
[doctor] okay , great . we can definitely do that . uh , just take it every night before bedtime .
[patient] okay , that sounds good . thank you so much .
[doctor] you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ?
[patient] okay , that sounds good . thank you .
[doctor] you're welcome , and have a good rest of your day .
[doctor] so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs .
[doctor] she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed . | CHIEF COMPLAINT
Follow up irritable bowel syndrome (IBS).
HISTORY OF PRESENT ILLNESS
Ms. Brittany Edwards is a pleasant 32-year-old female who returns in follow up for irritable bowel syndrome (IBS) with functional abdominal pain, nausea, and vomiting.
Ms. Edwards was last seen in August 2019 with flares of abdominal pain and was diagnosed with irritable bowel syndrome that was treated with Bentyl. She had a previous prescription for Reglan that she received from the emergency room that she used as needed for nausea. She was instructed to start a low dose fiber supplement such as Citrucel daily, probiotics to help with gas and bloating, and Bentyl up to 4 times daily for intestinal cramping. She was instructed to discontinue Reglan and to use Zofran as needed for nausea. Neuromodulators such as Elavil and Buspar were discussed but not started.
Ms. Edwards continues to have intermittent abdominal symptoms. Monday through Thursday she has less flare ups of her symptoms but states she is currently having cramps and sharp pains. She describes she recently ate shrimp which caused her to have both upper and lower abdominal pain and bloating. However, she notices episodes of diarrhea after eating chicken alfredo and consuming alcohol. She does not believe the alfredo contributes to her symptoms. The patient states she consumes 2 drinks when out of either tequila or brown liquor and occasionally a martini. She does her best to avoid “heavy foods,” but ate fried chicken today without any symptoms. She has stopped drinking sodas which has been helpful. The patient reports passing 2-3 formed stools a day.
REVIEW OF SYMPTOMS
• Gastrointestinal: Positive nausea, diarrhea, and abdominal pain.
PHYSICAL EXAM
Alert and cooperative, appears stated age.
Respiratory
Lungs clear to auscultation bilaterally.
Cardiovascular
Heart regular rate and rhythm.
Gastrointestinal
Abdomen soft, non-tender, no masses or organomegaly. Normoactive bowel sounds.
ASSESSMENT
• Irritable bowel syndrome
Brittany Edwards is a 32-year-old established patient who returned today to discuss management of IBS and functional abdominal pain made worse by high stress, poor eating habits, and poor sleeping habits.
PLAN
I have encouraged dietary and lifestyle modifications as well as starting a neuromodulator, such as Elavil 25 mg at bedtime for IBS. She can use Bentyl 20 mg as needed 30-45 minutes before eating out at a restaurant. She can also use Zofran as needed for nausea. However, I have encouraged her to reduce greasy fatty foods and alcohol consumption.
INSTRUCTIONS
Send MyChart message in 1 month regarding any side effects of issues with Elavil or if dose adjustments are needed.
Return to clinic in 1 month or sooner if needed. |
D2N141 | virtscribe | [doctor] okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 .
[doctor] i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed .
[doctor] good morning , mr . watson , who is the nice lady you have with you today ?
[patient] hi , doc . this is my daughter , theresa . she is the one who helps me keep things straight .
[doctor] mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago .
[patient] uh , not that i recall .
[patient_guest] no , he has n't . he has been doing much better .
[doctor] good , i'm glad to hear that .
[doctor] before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ?
[patient_guest] his walking has improved . he's now able to walk to the dining room just fine . but he could not do that before surgery . he still has times where i have to help him .
[doctor] that's impressive , mr . watson .
[patient] yeah , i guess .
[patient_guest] now his bladder control did improve some after surgery , but now seems to have leveled out . so he is wearing diapers .
[doctor] no issues with sores from wearing the diaper ? and any decreased or painful urination ?
[patient_guest] no , not at all .
[doctor] and how about cognition ?
[patient] i think i'm better . i do n't feel lost when talking to someone anymore .
[patient_guest] dad and i both think my sister , hannah , summarized it best . she said " i feel like i can have a normal conversation with him again , "
[doctor] that's so wonderful ! now have you had any headaches or pain where the shunt is ?
[patient] no . has n't bothered me one bit .
[doctor] okay . and any pain in your belly at all ?
[patient] ca n't say that i have .
[doctor] okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ?
[patient] sounds good .
[doctor] okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in .
[doctor] all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan .
[patient] so what does that mean ?
[doctor] just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about .
[patient] all right so i'll come back in three months ?
[doctor] yep , that's right .
[patient] i do have a question for you though .
[doctor] yeah , of course .
[patient] do you think i will be able to drive again ?
[doctor] ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it .
[doctor] now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go .
[patient] okay . i kinda figured that anyway but i just thought i'd ask . i do n't like to burden anyone when i just need to run to the store but i also know that i need to be safe .
[doctor] yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement .
[patient] i sure hope so , doc .
[patient_guest] we really appreciate all that you've done . do we make the appointment out front ?
[doctor] yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?
[patient] thanks
[patient_guest] thank you .
[doctor] all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings .
[doctor] let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 .
[doctor] mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice .
[doctor] gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 .
[doctor] cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change .
[doctor] diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment . | CHIEF COMPLAINT
Follow up adult hydrocephalus, 3 months status post shunt surgery.
HISTORY OF PRESENT ILLNESS
Mr. Christopher Watson is an 86-year-old male who returns in follow up of adult hydrocephalus. This is his first visit since undergoing shunt surgery 08/01/2020. He is accompanied by his daughter, Theresa, together they give his history.
I have followed Mr. Watson since May 2020. He presented with 8-10 years of progressive gait impairment, cognitive impairment, and decreased bladder control. We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June 2020 and he underwent shunt surgery on 08/01/2020. A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.
Mr. Watson has had no hospitalizations or other illnesses since I last saw him. With respect to his walking, his daughter states that he is now able to walk to the dining room just fine but could not before his surgery. His balance has improved though he still has some walking impairment. With respect to his bladder control, initially there was some improvement, but he has leveled off and he wears a diaper. With respect to his cognition, both Theresa and the patient say that his thinking has improved. The other daughter, Hannah summarized it best according to the two of them, she said “I feel like I can have a normal conversation with him again.” Mr. Watson has had no headaches and no pain at the shunt site or in the abdomen.
PAST HISTORY
Urinary incontinence.
Adult hydrocephalus.
Gait impairment.
Cognitive impairment.
REVIEW OF SYSTEMS
• Constitutional Symptoms: Significant for impaired ability to carry out daily functions. Negative for fever or unintentional weight loss.
• Genitourinary: Significant for urinary incontinence and wearing a diaper. Negative for genital sores, decreased or painful output.
• Neurological: Significant for continued walking impairment and cognitive impairment. Negative for headaches, recent falls, or hallucinations.
• Psychiatric: Negative for depression, excessive worrying, or mood swings.
VITALS
Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.
PHYSICAL EXAM
Constitutional
Mr. Watson is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.
Head and Face
The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.
Neurological
Mental status: Tested for recent and remote memory, attention span, concentration, and fund of knowledge. He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations. Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice. This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.
Gait: Tested using the Tinetti assessment tool. He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28. This has slightly improved from his initial score of 15-17/28.
Cranial Nerves: Pupils are equal. Extraocular movements are intact. Face symmetric. No dysarthria.
Motor: Normal for bulk and strength.
Coordination: Slow for finger-to-nose.
RESULTS
CT scan of the head from 10/15/2020: It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm. By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection. This was not noticed by the radiologist who stated no extra axial fluid collections. There is also substantial small vessel ischemic change.
ASSESSMENT
• Adult hydrocephalus.
• Gait impairment.
• Urinary incontinence and urgency.
• Cognitive impairment.
Mr. Watson has made some improvement with his hydrocephalus since shunt surgery. There is a tiny fluid collection in the right parietal region. I do not believe that this tiny amount of fluid is symptomatic, and it was not documented by the radiologist when he read the CT scan.
Mr. Watson asked me about whether he will be able to drive again. Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test. I would certainly be happy to recommend such a test if I believe he is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time. I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.
PLAN
I had a long discussion with the patient and his daughter. We are all pleased that he has started to make some improvement with his hydrocephalus because of the fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.
INSTRUCTIONS
Follow up in 3 months. |
D2N142 | virtscribe | [doctor] amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable .
[doctor] hi miss taylor , how are you today ?
[patient] hi , i'm- i'm good , thank you .
[doctor] thanks for coming in today .
[patient] yeah , no problem .
[doctor] so how have things been going for you ?
[patient] uh , they've been all right . i'm struggling with not drinking . i wanted to discuss that , uh , shot that you had mentioned last time , but we did n't get to discuss it too much .
[doctor] okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ?
[patient] on monday .
[doctor] okay , so you've gone a couple days without it ?
[patient] yeah , yeah i have .
[doctor] yeah , and had you been drinking for a while ?
[patient] yep .
[doctor] how much had- how much had you been drinking ?
[patient] um , four or five times a week hard alcohol , so , you know .
[doctor] okay . well it will certainly help your blood pressure if you're able to stop drinking .
[patient] yeah , yeah i- i- i agree with you .
[doctor] okay . are you taking your blood pressure medications ?
[patient] yeah , but i'm only taking half of the lisinopril .
[doctor] okay .
[patient] i- b- well , the first time i took it i felt lethargic and tired , so i only took a half dose the next time . i felt much better and i did n't have the headaches or the swooshing that started in my left ear . so i feel like it's definitely helping but i do n't know ... i know it's not gon na be okay until i stop drinking .
[doctor] and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ?
[patient] yeah i'm taking the full dose of that medicine too , and no none of those symptoms .
[doctor] okay . anything else i should be aware of or that we should be checking ?
[patient] mm , no .
[doctor] okay , good . are you doing the blood pressure checks at home ?
[patient] yes . yes i am .
[doctor] okay good . what kind of numbers are you seeing ?
[patient] well , in the morning i'm seeing lower numbers than in the evening , um , where i run anywhere from like 130 to 145 or 150 over 95 to 100 on the bottom .
[doctor] okay .
[patient] but in the evenings if i sit there for a while and then take it , it goes down . kind of like when i come here it's always high but then it goes down . in the mornings it's generally more normal where it's supposed to be .
[doctor] uh- .
[patient] mm , also i'm taking my medicine in the morning when i get up instead of in the evening .
[doctor] yeah , so it sounds like we are not too far out of where we wan na be .
[patient] right , mm-hmm .
[doctor] okay . well let me get a listen to your heart , go ahead and hop up here .
[patient] okay .
[doctor] use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ?
[patient] no .
[doctor] any recent travel or contact or exposure to the coronavirus ?
[patient] nope .
[doctor] have you received your coronavirus vaccine ?
[patient] yes , on february 9th .
[doctor] okay , great . all right well i'm just going to look at your ankles and feet , i'm looking for any signs of swelling .
[patient] okay .
[doctor] all right , well everything looks good . you can go ahead and sit up miss taylor . all right , so the good news is everything is looking okay . i think we both agree if you were able to stop drinking your blood pressure would cease to be an issue for you .
[patient] yeah i agree with that .
[doctor] so let us discuss the potential medicine to help you with that . what it does is it blocks some of the brain receptors that alcohol stimulates and it tricks the brain into thinking it does not need alcohol , thereby cutting down the urges .
[patient] the urge to drink or the constant thinking about it ?
[doctor] it actually will help with both .
[patient] okay . so is it like a one-time thing ?
[doctor] generally the shot is given about once a month , it can also be given as a daily pill , but the shot does tend to work a bit better .
[patient] yeah i've taken things like this in the past and if it is a pill , i know i wo n't take it . with a shot , it's not like you can un-take it .
[doctor] yeah that's true . and the shot has been shown to work , it is more just a matter of getting you in to get your shot a month later with the nurse .
[patient] yeah , sure , sure .
[doctor] okay , so it's called naltrexone . i think the other name might be vivitrol . like i've said , the research on it is pretty good .
[patient] i think i may have taken the naltrexone before .
[doctor] okay , yeah , maybe you have .
[patient] yeah , if it was available in a pill form then i'm almost certain i've tried it b- before .
[doctor] okay . if this sounds good though , we can go ahead get you started with the shot . i am looking and it looks like we have you coming back in on may 17th for your first shot , does that sound good ?
[patient] yeah , yeah , that sounds great . are there any possible side effects ?
[doctor] yeah , some people will experience some nausea , headache , dizziness , anxi- anxiety , tiredness and trouble sleeping , but generally the side effects are mild and should go away within a few days .
[patient] okay .
[doctor] then we can schedule you for a follow-up in june to see how you are doing .
[patient] all right that sounds good .
[doctor] all right great . well otherwise stay with your current medicines , keep checking your blood pressure , and let's see if we can stop the alcohol for good . let us know if you have any questions or any issues come up after you receive the first dose .
[patient] all right , sounds good , thank you .
[doctor] you are welcome , have a good rest of your day .
[patient] you too .
[doctor] miss taylor is drinking alcohol four to five days per week to excess . no tobacco , no substance abuse , skin is moist , good trigger . on exam she is alert , pleasant , in no acute distress . she is not diabetic , there is no tremor , no cva tenderness , chest clear to percussion and auscultation , unlabored breathing , cardiac rhythm regular , no murmur , no gallop , jvp flat , with a head at 90 degrees . she does not appear anxious , agitated or depressed . my impression , alcohol use disorder . she would like to start naltrexone which we have previously discussed . she will take the injectable form and start on may 17th . we reviewed side effects and risks . the potential benefit of alcohol cessation would be highly beneficial to her for many reasons . hypertension , she is taking lisinopril 10 milligrams daily and hydrochlorothiazide 12.5 milligrams daily . quite possibly her blood pressure will improve completely with cessation of alcohol . her target bp is 130 to 140 over 70 to 80 . i will see her back week of june 14th , which is likely around the time of her second naltrexone injection . i recommend upgrading influenza vaccination and shingrix . number two , she did defer this .
| CHIEF COMPLAINT
Hypertension.
Alcohol use disorder.
HISTORY OF PRESENT ILLNESS
Amanda Taylor is an 72-year-old woman who presents for a follow-up for hypertension. History includes significant alcohol use disorder and mild hypercholesterolemia. At last visit on April 16, BP was 130/90. After presenting at 150/100 she was prescribed hydrochlorothiazide 12.5 mg by mouth once daily and lisinopril 20 mg by mouth once daily. CMP and CBC were essentially unremarkable.
Mrs. Taylor admits to consuming alcohol 4-5 times a week and is interested in Naltrexone injections. She acknowledges that her blood pressure would likely improve if she stopped alcohol consumption. She is checking her blood pressure in the morning and evening, stating it is higher at night but will improve after sitting for a few minutes. She is averaged 135-145 or 150 over 95-110.
She experienced side effects from lisinopril, such as headaches, “swooshing” in her left ear, and lethargy. She took half a dose and did not experience the side effects.
PAST HISTORY
Medical
Hypertension.
Hypercholesterolemia.
Alcohol use disorder.
CURRENT MEDICATIONS
Lisinopril 20 mg tablet once daily.
Hydrochlorothiazide 12.5 mg once daily.
PHYSICAL EXAM
Constitutional
No distress. No fever. No tobacco or other substance use.
Neurological
Alert.
Psychological
She does not appear anxious, agitated or depressed.
Neck
JVP flat with a head at 90 degrees.
Respiratory
No cough or shortness of breath. Chest clear to percussion and auscultation. Unlabored breathing.
Cardiovascular
No CVA tenderness. Cardiac rhythm regular. No murmur. No gallop.
Musculoskeletal
No ankle edema.
Integumentary
Skin is moist. Good trigger.
ASSESSMENT
• Alcohol use disorder.
• Hypertension.
Mrs. Taylor presents for a follow-up for hypertension. History includes significant alcohol use disorder and mild hypercholesterolemia. At last visit on April 16, BP was 130/90. After presenting at 150/100 she was prescribed hydrochlorothiazide 12.5 mg by mouth once daily and lisinopril 20 mg by mouth once daily. CMP and CBC were essentially unremarkable.
PLAN
Alcohol use disorder
I will start her on naltrexone which we have previously discussed. She will take the injectable form and start on May 17. We reviewed side effects and risks. The potential benefit of alcohol cessation would be highly beneficial to the patient.
Hypertension
She will continue taking lisinopril 10 mg/day and hydrochlorothiazide 12.5 mg daily. Quite possibly her blood pressure will improve significantly if she is able to completely stop consuming alcohol. Target BP is 130-140/70-80. I will see her back week of June 14 which likely will be the time of her second naltrexone injection.
Recommend upgrading influenza vaccination and Shingrix #2, she defers this.
INSTRUCTIONS
Call the clinic with any questions. Make follow up appointment week of June 14th.
|
D2N143 | virtscribe | [doctor] next patient is grace ross . date of birth 8-23-97 . ms. ross is a new patient . she's here today for a full spectrum std testing . the patient states that she's having symptoms of discomfort , a change in discharge , and odor in her vaginal region . she says that the right side of her vagina is starting to become painful . she denies any fevers or chills . she reports , that she recently learned , her partner has been in sexual encounters with other people , and she wants to be evaluated for all stds .
[doctor] hello , ms. ross . i'm dr. diaz . it's good to meet you .
[patient] hi . yes . nice to meet you , too .
[doctor] so , how are you doing today ? i hear that you're here for std testing . is that correct ?
[patient] yeah . actually , i found out earlier this week , that my boyfriend has been cheating on me , for some time . i'm really worried , that i could have caught something , you know ?
[doctor] mm-hmm .
[patient] i wanted to make sure i do n't have anything .
[doctor] yeah . i'm sorry to hear that . of course , we can do that today . um . well , let's see . how do you feel ? do you have any symptoms ?
[patient] well , um , i started noticing some weird discharge last week .
[doctor] mm-hmm .
[patient] uh , it smells different . it's not the same color , or consistency , as usually , it is .
[doctor] right .
[patient] um . that part did n't even phase me , until i noticed that the right side of my vagina was hurting . just sore , you know , but that has n't gone away .
[doctor] yep . nah , that does sound like a cause for concern . how long have you been with him ?
[patient] hmm , we've been dating for three years .
[doctor] mm-hmm .
[patient] as far as , i can figure , he started cheating on me , i think , about three months ago .
[doctor] uh- . um , okay . do you ... have you ever had an irregular pap smear ?
[patient] well , yeah , i did , but it was back whenever i was 20 or so . it has n't ... and i have n't had one since .
[doctor] okay . and when was your last pap smear ?
[patient] uh , about six months ago . it came back normal , though .
[doctor] okay . good , okay . well , let's see ... let's take a look at you , and then , we'll get some samples for std testing . okay ?
[patient] all right .
[doctor] you'll hear me talk through your exam , so that i can get it all documented . uh- ?
[doctor] use my general physical exam template . pelvic exam demonstrates no external lesions . normal labia majora and labia minora . normal physiological discharge , with normal color and smell .
[doctor] ms. ross , i'm going to touch you , now . you'll feel my fingers , and the speculum in your vagina . you'll feel some pressure , now .
[doctor] cervix is normal . vaginal wall is normal . no cervical motion tenderness and no adnexal tenderness or masses noted . swabs were done for std testing .
[doctor] okay , ms. ross . everything looks good from a visual standpoint . i'm going to send off std testing for , uh , gonorrhea , chlamydia , trichomoniasis , and i'll have you give some blood for syphilis , hiv and hepatitis c. some of these tests will take longer than others . we will call you , if we see anything , but if you have n't heard anything , you can call us in three days for results .
[patient] okay . sounds good . thank you , so much .
[doctor] of course , my pleasure . and , if everything is normal , i'll see you again , at your next annual checkup .
[doctor] assessment : is screen for std .
[doctor] plan : discussed with patient , and please add that she is high risk due to an abnormal pap smear in the past , and the recent discovery of her sexual partner having multiple partners , for some period of time .
[doctor] end of recording . | CHIEF COMPLAINT
Full-spectrum sexually transmitted disease testing.
HISTORY OF PRESENT ILLNESS
Ms. Ross is a 23-year-old female who presents today as a new patient for full-spectrum STD testing.
The patient states that she is having symptoms of discomfort, a change in discharge, and an odor in her vaginal region. She says that the right side of her vagina is starting to become painful but denies any fever or chills. She states that she recently learned her partner of 3 years has been engaging in sexual encounters with other people for quite some time, and she wants to be evaluated for all sexually transmitted diseases.
Ms. Ross reports noticing a change in the odor, color, and consistency of her vaginal discharge last week. She notes that this did not alarm her until the right side of her vagina became painful and sore, which has not subsided. She states that she had an abnormal Pap Smear around the age of 20, but all her Pap Smears since then, including her most recent one approximately 6 months ago, have all been normal.
PHYSICAL EXAM
Genitourinary
Pelvic exam: No external lesions, normal labia majora and labia minora. Normal physiological discharge with normal color and odor. Cervix is normal, vaginal wall is normal, no cervical motion tenderness or masses noted. Swabs were obtained for sexual transmitted disease testing.
ASSESSMENT
• Screening for sexually transmitted disease.
PLAN
Ms. Ross is a 23-year-old female who presents today as a new patient for full-spectrum STD testing. We will screen her today for gonorrhea, chlamydia, trichomoniasis, syphilis, HIV, and hepatitis C. Patient is high risk due to an abnormal pap smear in the past and the recent discovery of her sexual partner having multiple partners for some period of time. We will call the patient with the results of the laboratory testing. |
D2N144 | virtscribe | [doctor] tyler nelson , date of birth : 3 , 6 , 1949 , mrn , 385729 . he is here today for ongoing management of rheumatoid arthritis . last time he was here , he received a steroid injection in his right knee . hello mr. nelson , how are you ?
[patient] um , about the same as last time . my knee is still swollen .
[doctor] that was your right knee , correct ? i take it the injection did n't help ?
[patient] it did , maybe for a couple of weeks .
[doctor] that's it ? and is it still painful ?
[patient] yeah , it's pretty painful , and now the whole leg is getting swollen .
[doctor] okay , what would you say your pain level is ?
[patient] i mean , right now it's about a 3 or so , but , typically on a normal day it's around 6 .
[doctor] okay , and its been swollen like that for how long now ?
[patient] since i was last here a couple weeks after that . so about , maybe two months now .
[doctor] okay , but before it was just the knee ?
[patient] yeah , the whole thing was n't swollen like this , but i tried to wear compression socks a lot of the time , but it has n't been helping .
[doctor] okay , okay , so that has n't been working for you ?
[patient] i mean , it helps to some degree , but it's still swollen , especially around the knee .
[doctor] hmm . has it been keeping you from doing things during the day ?
[patient] well , i slowed down a little bit , and i found a few things too fast . but when it really hurts , is when i've been sitting for a while , and then i have to try and get up . i'm so stiff getting up i have to use a cane to get my bearings . i mean , after a little bit , it loosens up , but that first getting up is real difficult .
[doctor] yeah , i can see , that makes sense . have you been taking your medication regularly ? your on xeljanz right ?
[patient] yeah , the xr , i think its , uhm , 11 milligrams a day ? yeah , but i'm taking it everyday , and i'm also taking celebrex which i started maybe 2 months ago .
[doctor] yes , the 200mgs daily . how's that working for you ?
[patient] pretty good , up until it started swelling again .
[doctor] okay , well come sit over here , and if you could take of your socks and shoes , and we'll take a look at your knee . and just to let you know , i have a service now that writes my note about the visit , so you'll hear me call things out and describe what i see fully .
[patient] okay , gotcha .
[doctor] right , so let's check your leg . can you straighten it , and does it hurt ?
[patient] yeah , when i try to straighten it all the way it does .
[doctor] okay , range of motion slightly diminished . i'm going to press here , okay ? and how about here , hmm , i see some pitting around the knee and ankle . normal capillary refill in the toes . does any of this area hurt ?
[patient] um , just kinda sore , like an old bruise ?
[doctor] so , i can feel that the knee is hot , and that means there's something going on , like some inflammation . so we can give you another steroid injection for that . i also want to get an x-ray of that knee , so we can see where all the swelling is coming from .
[patient] yeah . let's do it . sounds go to me .
[doctor] okay , and did we set up physical therapy for you last time you were here ?
[patient] yeah , that was some years ago , but that was the other knee .
[doctor] okay . so i think we'll set that up for you now . we'll also do an x-ray on that knee . i can send you for a physical therapy , and if nothing is helping , then we really might need to get a surgery consult to see what we can do with that knee .
[patient] okay , sounds like a plan .
[doctor] all right , so for today we'll go ahead and we'll give you the steroid shot . i'll try to see if i can get a little bit of fluid out before i do give you the injection . there might be no fluid , but i'll see if i can get anything out regardless .
[patient] okay . and that's a procedure you're going to do right now ?
[doctor] yep . once we're done talking here , and as far as the edema in your legs , uh , we'll take an x-ray to look for the cause , but there is a lot you can do as well . the compression socks are a good start . um , and also , do you eat a lot of salt ?
[patient] i mean , um , i mean i love my salty snacks .
[doctor] okay . well , salt does have a tendency to make your body hold on to water , reducing your salt intake could help with some of the swelling . you can also prop your feet up any time you get a chance , especially at night . and have you talked to your private care doctor about this at all ?
[patient] no , i figured i would just come here first .
[doctor] okay . so i think , try some of those things out first , and if it does n't help , definitely make an appointment with them , also , as you know , xeljanz is a high-risk medication , so we need to check your cmp levels every couple of months . so this time your levels are good , but do make sure to make an appointment for the blood work for next time .
[patient] all right . i can do that . thank you so much doc .
[doctor] yes , of course . well let me go ahead and get supplies and we'll get to work on your knee .
[doctor] fluid aspiration and steroid injection procedure . the risks , benefits , and alternatives were explained . the risks of steroid injection were explained , including , but not limited to : hypopigmentation , soft tissue atrophy , tendon ruptures , and transient hypoglycemia among others . verbal consent was attained . the right knee was , uh , um , accessed through the lateral approach with 3 milliliters of initially clear fluid , then bloo- blood tinged fluid . then the right knee was prepped in a standard-fashion . the right knee was injected with 80 milligrams of triamcinolone , and one milliliter of lidocaine . the procedure was tolerated well , with no complications . post-procedure instructions were given . patient will follow up with his pcp . thank you . | CHIEF COMPLAINT
Rheumatoid arthritis management.
HISTORY OF PRESENT ILLNESS
Mr. Nelson is a 72-year-old male who presents today for ongoing management of rheumatoid arthritis. He was last seen by me on 03/04/2021, where he received a steroid injection to his right knee. He continues to experience right knee pain and swelling. The pain level is 6/10. He notes when he stands after he has been sitting for a while, he has to use a cane to "get his bearings." The injection he received to the right knee at the last visit was only beneficial for a few weeks. The patient notes whole right leg swelling since the last visit. He usually wears support hose, which helps to some degree. He has not attended physical therapy.
PHYSICAL EXAM
Musculoskeletal
Lower right extremity: Swollen right knee, slightly reduced range of motion. Skin warm to touch. Lower right leg pits with pressure.
PROCEDURE
Fluid aspiration and Steroid injection.
Risks, benefits, and alternatives were explained. The risks of steroid injection were explained, including but not limited to, hypopigmentation, soft tissue atrophy, tendon ruptures, and transient hyperglycemia among others. Verbal consent was obtained. The right knee was accessed through the lateral approach with 3 mL of initially clear fluid then blood-tinged fluid. Then the right knee was prepped in a standard fashion. The right knee was injected with 80 mg triamcinolone and 1 mL lidocaine. The procedure was tolerated well with no complications. Post procedure instructions were given.
ASSESSMENT
• Rheumatoid arthritis management.
• High risk medication use.
• Right knee pain.
• Lower extremity pitting edema.
PLAN
Rheumatoid arthritis management.
The patient will continue Xeljanz XR 11 mg daily. He will also continue Celebrex 200 mg daily.
High-risk medication use.
The patient is currently on the high-risk medication Xeljanz. We will check his CMP levels and monitor periodically every couple of months.
Right knee pain.
He has right knee pain and swelling, with pain level 6/10. On exam today, the right knee continues to be hot, which is ongoing inflammation. We performed a fluid aspiration of the right knee today, see procedure note above. A steroid injection to the right knee was given today, see procedure note above. We will arrange for x-ray of the right knee and refer his to physical therapy.
Lower extremity pitting edema.
The patient notes whole right leg swelling since the last visit. He usually wears support hose, which helps to some degree. He has not seen his PCP. We discussed compression stockings, elevate feet, and a low salt diet. He will check with his PCP for further instructions. |
D2N145 | virtscribe | [doctor] uh , mrn49282721 . patient's name is jacqueline miller . use last visit exam where appropriate .
[doctor] hi , how are you doing , jacqueline ?
[patient] i'm pretty . good . how are you ?
[doctor] good as well . so it sounds like we're , um , under good control right now .
[patient] yes . it's doing much better .
[doctor] good , good . do you have any rash leftover ?
[patient] yeah , i have a- a small bit leftover . i started using , uh , doxycycline only one a day because i think the pharmacist said if it's getting better , to just limit it to once a day .
[doctor] okay , that sounds good .
[patient] but i was taking it twice a day and i did notice a lotta improvement .
[doctor] okay .
[patient] and then when i started doing it only once a day , it seems the same and it's not continuing to get better . so it's kinda plateaued a little bit .
[doctor] i see . um , are you breastfeeding at this time ?
[patient] no , i'm not right now .
[doctor] okay , good . so you- you should not be breastfeeding while you're on that medication .
[patient] yeah , actually i stopped breastfeeding and then asked for the doxycycline at that time .
[doctor] okay . even with the doxycycline , you can keep using the elidel .
[patient] okay . and i did n't take the elidel because when i read about it i got worried . so i wanted to just try the doxycycline and see .
[doctor] okay . so we can talk about the elidel . a lot of the things you read about is not actually relevant to the cream or ointment form , but it's about the oral form that's used in really high doses , longterm , after people have a heart transplant or a kidney transplant or something like that .
[patient] okay . i did n't realize that .
[doctor] yeah , and when you suppress the immune system that hard for that long , it can predispose you for developing cancers like hematologic type cancers . it does n't apply to as-needed use of the medicine , a cream or an ointment , okay ?
[patient] okay . then i can resume taking - taking the doxycycline twice a day again ?
[doctor] so let me clarify . what exactly are you using ? and then we'll look at you and figure out , okay ? so you're using the sulfacetamide wash ? uh , how frequently are you using that one ?
[patient] twice a day .
[doctor] okay , and that's not drying you out too much ?
[patient] no , that's fine .
[doctor] okay . and you're using the metro cream ?
[patient] yes .
[doctor] how often are you using that one ?
[patient] after my face wash , i immediately apply the cream .
[doctor] okay . and then , are you using any other kind of lotions or anything ?
[patient] no .
[doctor] so you're not using the cetaphil cleanser ?
[patient] i'm not .
[doctor] okay . and no neutrogena wipes ?
[patient] no wipes .
[doctor] okay . um , and then what about , um , any lotions that you're using ?
[patient] i'm not using any lotion right now , just those two .
[doctor] no lotion , okay . so that may be something else we should add in , a lotion to just help moisturize . but we'll see .
[patient] okay .
[doctor] um , and then again , when did you go down to just taking the doxycycline once a day ?
[patient] that was last week . so the first two weeks , i did twice a day .
[doctor] okay .
[patient] and then i started seeing improvement , and then i changed to just once a day .
[doctor] okay . let me take a look at your face here . i'm gon na describe for the transcriptionist what i'm seeing . you're fitzpatrick skin type iv , meaning you're not going to burn , you're going to sun tan , um , essentially , iv to v. and then on bilateral medial cheeks , there are a few really faint erythematous papules and just maybe a little bit of redness around and underneath your nostrils . so you're right , it's not totally gone .
[patient] yeah .
[doctor] i think i would go ahead and go back to twice a day , every day , with the doxycycline .
[patient] okay .
[doctor] uh , but i would pickup the elidel too .
[patient] okay , i can do that .
[doctor] i mean , out of known risks associated with medications , topicals are usually safer and preferable to oral medications . with that being said , doxycycline is low risk .
[patient] it is ? okay .
[doctor] um , and doxycycline can give you bad upset stomach or heartburn . um , it will make you sunburn , even if you never sunburn , so you have to protect yourself .
[patient] yeah , i mean , i feel sun sensitive whenever i go out , so i am taking all the precautions , with wearing a hat and all of that .
[doctor] great . i just wanted to make sure you knew about that .
[patient] yes , i did . thank you .
[doctor] all right . but i think to help get rid of it sooner rather than later , if insurance will cover the elidel , pick it up and start using it .
[patient] yeah , i did check . the insurance is not covering it .
[doctor] it's not ? okay . well , let's look around really quick because if you use a goodrx coupon , it will be around 30 to $ 40 or something .
[patient] okay .
[doctor] let's see .
[patient] so with your coupon , it was around $ 850 or something .
[doctor] ugh , yeah . that's way too much .
[patient] i agree . and- and because i also looked at the eucrisa that you recommended in my notes , and if it's still ex- if it's still expensive , i could try that instead .
[doctor] yeah , so it ... actually ... it is actually more expensive . i think the prices fluctuate .
[patient] okay .
[doctor] because now it's showing the cheapest of $ 70 , and when i looked before , it was around 30 to $ 40 .
[patient] yeah . if it was around $ 200 , i would've picked it up . but it was coming to around $ 850 after insurance .
[doctor] okay . so i've found the cream form . we could try ointment form .
[patient] you mean the tacrolimus ?
[doctor] yeah , mm-hmm .
[patient] okay .
[doctor] so if we send it to pick'n save or metro market ... let's see where else .
[patient] can you do the metro market ?
[doctor] yeah . let me put in the prescription and we'll see what we can find .
[patient] sure .
[doctor] pharmacy is what i'm trying to say .
[patient] okay . but it's not a steroid , right ?
[doctor] correct , it's not a steroid .
[patient] okay , good .
[doctor] it's called a calcineurin inhibitor . it's kinda like a steroid in that it calms inflammation .
[patient] okay .
[doctor] but it's not a steroid , so do n't use steroids on your face , for sure , as they'll make this kind of rash worse . but also , steroids carry the risk of causing thinning of the skin .
[patient] all right .
[doctor] these medications do n't cause thinning of the skin and they're not going to cause some other kind of rash . um , the thing to know is that sometimes five to 10 minutes after you put it on , it can cause this weird kind of tingly or needle-like sensation or make it redder or flush . but it should only last a few seconds and then go away . it's not an allergy or anything bad .
[patient] okay . got it .
[doctor] so it only lasts a couple seconds . it does n't mean it's going to happen again . it's nothing bad . it will still work , so keep using it as long as you know you can stand it , okay ?
[patient] okay , thank you for explaining .
[doctor] so i will say , " apply to rash on face twice daily , until resolved . "
[patient] okay . so only apply to the rash area ?
[doctor] yes , and keep using the face wash.
[patient] okay .
[doctor] i think you could just do it once a day . i do n't think you need to do it twice a day , just because i do n't wan na dry your sky out too much , okay ?
[patient] i never noticed that my face is dry or got thin . i feel so good after using it .
[doctor] i understand , but it could get dry and i do n't wan na create other problems for you .
[patient] all right . i'll just wash once a day with it . but it was feeling very good , like there's this little bit of moisture getting back in . with the other wash , when i would use it twice a day , i was drying out . but not with this one .
[doctor] i see . okay . well then do what feels good . if you do notice that you're starting to get dry , then reduce to once per day .
[patient] that sounds good .
[doctor] so to review , um , continue using the same face wash , continue with metro cream , and increase the use of doxycycline to twice a day .
[patient] okay .
[doctor] and then just do it until it's gone , and then do it for once a day for another week before stopping .
[patient] okay , sounds good .
[doctor] all right . and i'll rewrite your instructions here .
[patient] thank you so much .
[doctor] if there are any other questions or you're getting different instructions , feel free to reach out to me and we'll clarify , okay ?
[patient] okay .
[doctor] but in general , doxycycline is such a low risk . we're not gon na have you on this forever . but especially since we're adding the tacrolimus , i expect it will clear quickly .
[patient] sounds good .
[doctor] all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for another week before stopping .
[patient] okay .
[doctor] once the rash stops , you can stop the tacrolimus ointment . um , continue doxycycline another week and then stop . but you can keep using the wash and the metro cream .
[patient] okay , that sounds good . i can do that .
[doctor] and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .
[patient] all right .
[doctor] i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?
[patient] yeah , sounds good .
[doctor] do you have enough refills ?
[patient] yeah , i think so .
[doctor] okay . so it looks like you have another refill of the doxycycline , so you're good there . metro cream , you probably still have enough of that one .
[patient] yes , i do .
[doctor] all right . and i'll cancel the elidel cream , just so we do n't complicate your list . uh , you have plenty of the face wash still .
[patient] yes .
[doctor] okay . uh , and we'll get rid of the clindamycin from your list as well .
[patient] and what would you suggest for a moisturizer ?
[doctor] yeah , so for that i would do something really basic like vanicream . or even , if it's just really dry , you could use a little bit of petroleum jelly . um , i'll give you a couple samples , okay ? let's make sure we have a followup in about four weeks .
[patient] okay , thank you .
[doctor] okay . and i would stay away from any kind of anti-aging thing , any kind of plant thing . um , really let's just be sure we talk about any new products , or reach out to me if you're gon na try something else . um , let's go get those samples .
[patient] okay , that sounds good .
[doctor] for assessment and plan , perioral dermatitis , rosacea , including ocular rosacea , and copy and paste her patient instructions . i recommend that she gently wash her eyelids once a day with gentle cleanser such as vanicream , also use bruder mask as needed . | CHIEF COMPLAINT
Follow-up for perioral dermatitis.
HISTORY OF PRESENT ILLNESS
Jacqueline Miller is a 40-year-old female who is being seen today for a follow-up skin exam for perioral dermatitis. She also has a history of rosacea, including ocular rosacea. Today, she states that her perioral dermatitis is well-controlled, although it has not fully resolved. The patient was applying doxycycline twice a day with improvement, but her pharmacist advised her to reduce to once daily since it had started to improve; therefore, for approximately the past week, she has been using the doxycycline only once per day. She has not seen continued improvement but it has not worsened. She is using the sulfacetamide wash twice daily, denies drying of the skin, and reports that her skin is much improved moisturization. She also applies MetroCream immediately after using the sulfacetamide wash. She denies using other lotions and products, Cetaphil lotion or soap, or Neutrogena wipes. The patient did not begin Elidel because it is not covered by her insurance, and she was concerned about possible side effects from the medication.
PAST HISTORY
Medical
Perioral dermatitis.
CURRENT MEDICATIONS
Doxycycline cream. Apply twice daily.
MetroCream.
Sulfacetamide wash. Apply topically twice daily.
PHYSICAL EXAM
Integumentary
Skin inspection of the face was performed today. On bilateral medial cheeks, there are a few, very faint, erythematous papules with mild redness around and underneath the nostrils. Fitzpatrick skin type is 4 to 5.
ASSESSMENT
• Perioral dermatitis
• Rosacea, including ocular rosacea
Jacqueline Miller is a 40-year-old female who presented today for follow-up for her perioral dermatitis, which has improved but not resolved. She decreased her doxycycline per her pharmacist’s recommendation, which possibly stagnated the resolution of symptoms.
PLAN
Perioral dermatitis.
I counseled the patient about the risks and benefits of doxycycline and recommended she resume twice daily application until she reaches full resolution, and at that point she should reduce application to once a day for an additional week. The patient will not be using Elidel as I reviewed the cost of the medication and without insurance, it was too expensive. I provided a prescription for Tacrolimus and counseled her on possible side effects of using the medication. She will continue with Sulfacetamide face wash once a day. Also, use Bruder mask as needed.
Rosacea, including ocular rosacea.
Continue using MetroCream twice daily. I recommended to gently wash her eyelids once daily with a gentle cleanser and try a gentle cream such as Vanicream.
INSTRUCTIONS
Call the clinic if symptoms worsen. The patient will have a follow-up appointment in 4 weeks. |
D2N146 | aci | [doctor] hey good morning bobby how are you
[patient] i'm doing okay i as you're aware doctor miller sent me over for this pain in my belly that i've had for several weeks they did he did an ultrasound and and said i had gallstones and they recommended i stay several way from some high fat food but i'm just still having a lot of pain and he referred me to you
[doctor] alright well i'm i'm sorry to hear that you're having pain but i i'm glad that he sent you over to see me i wan na talk a little bit more about that pain can you describe the kind of pain that you feel
[patient] well it's it's on the right hand side of my belly it's it's right underneath my ribs and it feels like a a squeezing severe pain it comes and goes but when it comes it's really severe and i get kind of nauseated and sick in my stomach
[doctor] okay and then when you get that pain can you rate that pain for me on a scale like zero being none ten being the worst pain you've ever been in your life
[patient] when it's severe it's it's probably an eight
[doctor] okay alright and then time wise are we looking at can it just come and go anytime or is it specifically around mealtimes how how does that pain kinda wax and wane for you
[patient] most of the time it comes right after i eat
[doctor] okay
[patient] but it also can come on a couple of hours after i eat also so it's either immediately after i eat or a couple hours later but it's related to eating
[doctor] okay
[patient] you know i like to eat right
[doctor] do n't weigh all so speaking of eating let's talk a little bit about your diet i see here on your chart that you're a type two diabetic and it looked like that you were gon na handle that with diet and exercise let's talk about that a little bit
[patient] well you know i my my diet was worse when i before i was diagnosed with the the type two diabetes
[doctor] okay
[patient] and since then i've cut back on sugar and i started a little bit of a keto diet and i've lost about twenty five pounds over the last three months
[doctor] okay so other than the weight loss how how is your diet is that has that been working out for you i mean do you does does that does that fit your lifestyle pretty well
[patient] yeah it does it does it it i was surprised it was n't as hard as i thought to go back and cut back and go more of a keto diet
[doctor] okay
[patient] but you know trying to cut out all those carbs my symptoms got better
[doctor] yeah
[patient] with the diabetes and my my blood sugars are improving but i still get that pain underneath the ribs
[doctor] yeah and that can happen and one of those things that causes that is that those intake of that fatty foods which is you know kind of the the keystone or the hallmark of the keto diet and have you noticed any improvement when you do cut out that fatty food and has that been difficult since you are watching your carb intake
[patient] the fatty food it is a little bit difficult you know i like those pork grinds and you know i i've had to kind of cut those out they were a nice staple for me when i was on the keto diet but i have cut out the those pork rinses because those were just so delicious and you know i would say it's a little bit better but i still get that pain
[doctor] okay and then do you have any family history of gallbladder disease
[patient] yeah but you know you know i knew that was coming both my dad and my mother both had gallbladder disease and had to have their gallbladders off
[doctor] okay so both both your parents your mom and your dad had your had their gallbladders taken out
[patient] yeah
[doctor] okay and then i wan na talk a little bit about your activity level and your and and if you're exercising has this affected your ability to to get out and exercise
[patient] not really i mean i usually i got ta watch it around meals you know but i've never been a big exerciser right after eating anyhow but you know i'm i'm so glad springs here because it gives me that opportunity to get back out and you know i love photography i i love nature of photography and with the with the the woods going from you know that dark barron look to coming alive with that green and and butting i i love to get out and take foot photographs there
[doctor] that's awesome to hear yeah i my wife and i like to go over and take nature hikes through the new park behind the rex center that just opened up have you ever been over there to do any any picture taken we've got a bunch of beautiful nature pictures that we took about a week ago
[patient] no i have n't been there i might have to try that out yeah
[doctor] yeah it's awesome
[patient] i like to get down near the river that's where i i like to catch especially around spring time
[doctor] that's great yeah next time you come in maybe you can bring in some of your pictures that'd be awesome to see
[patient] okay cool
[doctor] so i'm just curious talking about your symptoms here have you had any fevers you mentioned something about nausea but have you actually vomited from those symptoms
[patient] there's times when the pain is really bad for a couple of days i've had some what i i would describe as low grade fevers and yes you're right i have feel nauseated but i have n't thrown up
[doctor] okay so if it's okay with you i'm gon na go ahead and do a quick physical exam your vital signs look good today blood pressure was one twenty eight over eighty eight respiratory rate was sixteen your pulse rate was sixty eight you were afebrile today which is a good thing and your oxygen saturation on room air was ninety nine percent taking a listen to your heart here your heart is regular of rate and rhythm no i do n't hear any ectopic beats no clicks rubs or murmurs noted listening to your lungs here they are clear and equal bilaterally to auscultation now i'm gon na go ahead and do an an abdominal exam i do note positive bowel sounds soft nondistended abdomen however you are positive for some slight guarding there to the right upper quadrant but i do n't note any rebound tenderness now i'm gon na press slightly here beneath your ribs on the right hand side now take a breath in does that hurt when i press
[doctor] so i i see that you're guarded there so i'm gon na say that that it did hurt when i it did hurt when i
[patient] absolutely that hurts so much when you push right there
[doctor] okay
[patient] sorry i was just trying to capture capture my breath
[doctor] okay that's that's no problem so you are positive for murphy's signs but i do n't appreciate any peritoneal signs so let's talk a little bit about your results that i reviewed before you came in today so your abdominal ultrasound shows multiple gallstones present in the gallbladder and i do appreciate some mild thickening now the common bile duct size is within normal limits at four . one millimeters now let's talk a little bit about my assessment and plan for you okay i do believe you have some mild cholecystitis with gallstones i do n't appreciate any frank obstruction but it looks like your gallbladder is inflamed and it looks like that's happened maybe over the last few weeks since you've been having those symptoms now since you have n't had any improvement with dietary modifications i am going to make the recommendation that we do remove your gallbladder and i would like to perform a laparoscopic cholecystectomy now what that means is i'll make a few small incisions and insert a scope with some of those instruments that's gon na remove that gallbladder through one of those little bitty incisions now the surgery is gon na take about an hour to an hour and a half and you'll probably spend the night in the hospital because we just wan na monitor you post procedure to make sure everything is okay you're still gon na wan na avoid those high fat foods after surgery and eat foods that are gon na be high in fiber now do you have any questions about what our assessment and plan is for for this
[patient] no no questions today
[doctor] okay now the other thing
[patient] how soon can i how soon will i be able to get up and get moving back outside after the surgery
[doctor] so the good news is since it's a laparoscopic procedure you're gon na be back on your feet pretty quick now for the first twenty four hours i'm gon na want you to take it pretty easy but after a couple of days if you feel like moving around on some solid ground you know we do n't want you hiking or anything like that but if you feel like moving around on some solid ground you can get up and walk around within a day or two and then in about a week or so i'll see you again and then we'll release you to go get back out there in nature
[patient] okay thank you very much
[doctor] you're very welcome the other thing i wan na talk briefly about is now your not your type two diabetes i want you to follow up with your physician just to make sure that you're handling your diabetes especially the fact that you're gon na have surgery and those type of things and we will just continue to monitor your diabetes as has been outlined by your your additional either your endocrinologist or your primary care provider i'm gon na have the nurse come in and get some paperwork signed and if you do n't have any questions for me i will see you next week and we will get this gallbladder out
[patient] well thank you very much i'm looking forward to i i do n't want anymore of that pain so
[doctor] alright that sounds good we'll see you next week then
[patient] okay take care
[doctor] yeah | CHIEF COMPLAINT
Abdominal pain.
MEDICAL HISTORY
Patient reports history of type 2 diabetes.
SOCIAL HISTORY
Patient reports enjoying nature photography.
FAMILY HISTORY
Patient reports family history of cholelithiasis. Both of his parents have had cholecystectomies.
REVIEW OF SYSTEMS
Constitutional: Reports low-grade fevers.
Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting.
VITALS
Blood Pressure: 128/88 mmHg.
Respiratory Rate: 16 breaths per minute.
Heart Rate: 68 beats per minute.
Oxygen Saturation: 99% on room air.
Body Temperature: Afebrile.
PHYSICAL EXAM
Respiratory
- Auscultation of Lungs: Clear and equal bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No ectopic beats. No murmurs, clicks, or rubs.
Gastrointestinal
- Examination of Abdomen: Soft, nondistended abdomen. Positive slight guarding to the right upper quadrant, but without rebound tenderness. Positive for Murphy signs. Peritoneal signs not appreciated.
- Auscultation: Bowel sounds normal in all 4 quadrants.
RESULTS
Abdominal ultrasound obtained at an outside facility is reviewed today. This demonstrates multiple gallstones present in the gallbladder. I do appreciate some mild thickening. The common bile duct size is within normal limits at 4.1 mm.
ASSESSMENT AND PLAN
1. Mild cholecystitis with gallstones.
- Medical Reasoning: Based on the patient's symptoms, exam findings, and ultrasound, I do believe he has some mild cholecystitis with gallstones. I do not appreciate any frank obstruction, but it looks like his gallbladder is inflamed. This appears to have happened maybe over the last few weeks or since he has been symptomatic.
- Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. The preoperative, intraoperative, and postoperative courses of care were described and discussed. I explained the surgery will take approximately 1 to 1.5 hours, and he will probably spend the night in the hospital for post-procedure monitoring. We also discussed that he should avoid high fat foods after surgery and eat foods that are high in fiber. All questions were answered.
- Medical Treatment: Since he has not had any improvement with dietary modifications, I recommend a laparoscopic cholecystectomy. A mutually agreed upon surgical date has been scheduled for 1 week.
2. Type 2 diabetes.
- Medical Reasoning: The patient is currently managing his diabetes with diet and exercise.
- Patient Education and Counseling: I advised the patient he should refrain from hiking in the immediate postoperative period; however, he may return to walking outdoors on solid ground 1 week status post-surgery.
Medical Treatment: I recommended he follow up with his physician regarding his impending surgery. We will continue to monitor his diabetes as has been outlined by either his endocrinologist or his primary care provider.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up with me 1 week status post-surgery. |
D2N147 | aci | [doctor] hi matthew how are you the medical assistant told me that you injured your shoulder
[patient] hey yeah i'm i'm hanging in there
[doctor] what happened
[patient] yeah so well when i was younger i used to be a little bit more active with my friends with the playing
[doctor] pick up football and so you know me being a little bit older now i thought i'll take back up with no problem well i did i tried and all the other guys were a little bit bigger than me so i got i got tackled a couple of times and it just
[patient] i kinda landed on my shoulder a little bit weird one time and so like i got back into the game i was okay but yeah ever since then the past couple of days it's just been it's been really bothering me
[doctor] okay alright and so when exactly did this happen
[patient] yeah i'd say maybe it was probably about last weekends so i'd say about like four days ago
[doctor] okay well i'm happy at age 67 you're out there playing tackle football so good good for you and was it your right shoulder or your left shoulder that you injured
[patient] it was my right
[doctor] okay and are you right or left handed
[patient] i'm right handed
[doctor] okay and have you had any numbing or tingling in your fingers at all
[patient] no fingers have been okay
[doctor] okay and any problems with the strength of the arm at all are you able to grab a cup of coffee
[patient] yeah i hand's doing okay i can grab yeah i'm just trying to avoid lifting anything yeah anything anything anything a little bit too heavy like i had a chipment command so i had a box in the driveway the other day and reaching down and picking up the box was a little tough
[doctor] okay and where exactly on your shoulder does it hurt
[patient] yeah it's kinda on the on the back side right right around here
[doctor] mm-hmm okay alright and are you able to lift up your shoulder so that your shoulder touches your ear at all
[patient] yeah no that's that's that's hurting a little bit
[doctor] okay alright and what have you taken for the pain
[patient] just a little bit of tylenol trying to take it easy
[doctor] did that help at all
[patient] it it kinda like kept it at the same spot that has been but it really did n't make it go down
[doctor] okay so are your symptoms any better since it happened or they about the same
[patient] no they are about the same
[doctor] okay and any neck problems did you injure your neck when this happened
[patient] no neck has been okay
[doctor] okay and any other joint problems like does your elbow hurt on that side or your wrist or is it just your shoulder
[patient] nope the the rest of it's doing okay it's just the just the shoulder
[doctor] okay and any other orthopedic injuries in the past have you ever injured that shoulder before as far as you know
[patient] nope nope that one that one's been fine
[doctor] okay and any any other surgeries or any other medical problems
[patient] i mean i had a appendicitis so i had an appendectomy
[doctor] okay
[patient] maybe like three four years ago but that's about it
[doctor] okay alright well i'm just gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so and last thing have you had any fever or chills since this happened at all
[patient] a slight headache but no no no fever
[doctor] okay did you hit your head when you when this happened
[patient] a little bit
[doctor] okay alright did you pass out
[patient] nope nope stayed conscious throughout
[doctor] okay alright well looking at your vital signs here in the office you do n't have any fever your blood pressure looks quite good it's about one twenty two over seventy six your heart rate is appropriate at eighty two beats per minute and your oxygenation is ninety five percent on room air on your cervical spine exam there is no tenderness to palpation of the cervical spine there is full range of motion on head exam there does not appear to be any trauma there is no ecchymosis or bruising on the right shoulder exam on your musculoskeletal exam there is pain to palpation of the posterior shoulder at the acromioclavicular joint there is decreased abduction and adduction to about ninety degrees only there is there is a he has pain with supination and pronation of the right arm and there is a palpable radial radial artery pulse okay so what does that mean that just means that you have some you know evidence of the injury there and we'll we're gon na talk about that so i had the nurse do a shoulder x-ray on you before i came in the room and the results of your right shoulder x-ray showed that you have an acute acromioclavicular joint fracture so you just have a a a small fracture of the acromion i do n't think that it it's gon na be anything that we need to do surgery for so let's just talk a little bit about my assessment and plan so for your right shoulder injury for your acute acromioclavicular joint fracture i wan na go ahead and just put you in a sling for now i wan na go ahead and prescribe meloxicam fifteen milligrams once a day i wan na go ahead and just order a cat scan of your right shoulder just to kinda get a better look of how the joint looks and we're gon na go ahead and refer you to physical therapy to strengthen your shoulder in hopes of avoiding surgery in the future how does that sound
[patient] yeah that that sounds great just being able to take a little bit of something for the pain would would would be really appreciated
[doctor] okay do you think you need something stronger than meloxicam
[patient] no i'll give that a shot
[doctor] okay
[patient] and see how that goes
[doctor] okay any questions
[patient] when can i get back out on the field
[doctor] well you ca n't play taggle football for a while you have to have this fracture healed
[patient] okay
[doctor] and i would avoid doing it you know as we get older you know our bones get a little bit weaker so i would avoid the tackle football maybe flag football in the future okay
[patient] yeah yeah that sounds good
[doctor] okay anything else
[patient] no i think that's that's been great thank you so much
[doctor] okay you're welcome have a good day bye
[patient] thanks | CHIEF COMPLAINT
Right shoulder injury.
HISTORY OF PRESENT ILLNESS
Matthew Allen is a 67-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of a right shoulder injury. The patient sustained this injury 4 days ago, when he was tackled a couple of times playing pick up football and landed on his right shoulder. He states that he was able to return to the game, however he has had pain since that time. The patient locates his pain to the posterior aspect of his shoulder. He denies any numbness or tingling in his fingers. He states that the strength in his hand is okay; however, he has been trying to avoid lifting anything too heavy. Mr. Allen denies being able to touch his shoulder to his ear because of pain. The patient has been taking Tylenol for pain, which does not provide relief. He denies any neck problems or other joint problems. The patient denies any previous orthopedic injuries to his right shoulder. He denies any fever or chills since the injury, but does note a headache. The patient states that he hit his head at the time of the injury but did not pass out.
SURGICAL HISTORY
The patient has a history of an appendectomy 3 to 4 years ago.
REVIEW OF SYSTEMS
Constitutional: Denies fever or chills.
Musculoskeletal: Reports right shoulder pain. Denies neck pain.
Neurological: Reports headache. Denies numbness or tingling.
VITALS
BP: 122/76.
HR: 82 bpm.
SpO2: 95% on room air.
PHYSICAL EXAM
NECK: Examination of the cervical spine reveals no tenderness to palpation. Full ROM.
HEAD: There does not appear to be any trauma. No ecchymosis or bruising.
MSK: Examination of the right shoulder reveals pain to palpation of the posterior shoulder at the acromioclavicular joint. There is decreased abduction and adduction to about 90 degrees only. Pain with supination and pronation of the right arm. Palpable radial artery pulse.
RESULTS
X-ray of the right shoulder reveals an acute acromioclavicular joint fracture.
ASSESSMENT
Right shoulder acute acromioclavicular joint fracture.
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 an acute acromioclavicular joint fracture. The plan is to place the patient in a sling and prescribe meloxicam 15 mg once a day to treat his pain. I also recommend that we obtain a CT scan of the right shoulder to evaluate further. I recommend that the patient attend formal physical therapy to strengthen his right shoulder in hopes of avoiding surgery in the future. In the meantime, I have advised him to avoid tackle football. |
D2N148 | aci | [doctor] hi jeremy how are you the medical assistant told me that you injured your back
[patient] yeah i was moving some boxes when my son was moving out of his college dorm and i really hurt my lower back
[doctor] okay how long ago did that happen
[patient] this was about four months ago
[doctor] about four months ago okay that's quite a long time and you're just seeing me now for it
[patient] yeah the appointments were backed up and i tried some pt at my gym but it it really did n't seem to help and i was really concerned
[doctor] okay and what exactly are your symptoms are you having pain when you're just sitting there or when you're moving around for a very short period of time it felt like i was gon na tapple over i like i could n't support my my upper body weight and then my right toe or the the toes on my right foot tingled a little bit but that went away after about an hour okay are you still getting that numbing and tingling periodically in your feet or is that completely gone
[patient] that's completely gone it it just happened when i first felt the the tweak in my lower back i felt that sensation but i have n't since
[doctor] okay and how about any difficulty or weakness in your legs
[patient] only if i'm carrying something heavy otherwise it seems relatively normal but i i feel the sensation so i'm a little nervous about carrying something heavy
[doctor] okay and are and do you still have pain down there in your lower back if i turn a certain way or if i roll over in my sleep i'll wake up from it from a like a sharp pain but then that that goes away if i if i position myself the right way okay and what have you been taking for the pain
[patient] i took some tylenol i took some ibuprofen i've tried heat i've tried ice and nothing really seems to help
[doctor] okay is the ibuprofen any better than the tylenol
[patient] a little bit but for sure a shorter period of time
[doctor] okay and did you get any stomach upset from the ibuprofen
[patient] no i try not to take too much so i i do n't have an upset stomach from it
[doctor] okay and did you go to like an urgent care centing or an emergency room have you had any imaging on this at all
[patient] i went to an urgent care and they wanted me to do an mri but i was a little concerned because i think we maxed out our insurance so i i did n't do it because it started to feel better but because it's been going on so long i'm i'm a little bit concerned now i i do wan na actually move forward with that
[doctor] okay alright and any other symptoms any problems with like your bladder or your bowels any incontinence or you know you feel like you ca n't go to the bathroom
[patient] no i have n't had any of those issues
[doctor] okay alright and any other any other past medical history do you that you have any
[patient] i had knee surgery about two years ago on my right knee
[doctor] okay
[patient] that went fine i rehabbed it pt has been fine it it feels about ninety five percent ever since
[doctor] okay and what did you have done to your right knee
[patient] it was a total knee replacement
[doctor] okay a total knee replacement in twenty eighteen is that what you said
[patient] no it was actually about two years ago so it's the spring of twenty twenty
[doctor] okay alright alright well i wan na go ahead and just move on to a physical exam i'm gon na be calling out some of my exam findings
[patient] mm-hmm
[doctor] now you have you had any fever or chills with this
[patient] no
[doctor] okay alright alright so looking at your vital signs here in the office you know they look really good your you you do n't have any temperature your blood pressure is good it's about one seventeen over fifty six
[patient] mm-hmm
[doctor] your heart rate is nice and slow at sixty eight and your oxygenation is fine at ninety five percent on room air so that means everything looks good
[patient] good
[doctor] on your neck exam i i do appreciate some bony protuberance of the c5 c6 do you have any pain when i touch here
[patient] no
[doctor] no okay on your lumbar spine exam i do appreciate do you have pain when i touch here
[patient] no
[doctor] okay so there is no pain to palpation of the lumbar spine there is decreased flexion and extension of the lower back the patient does have a positive straight leg raise and there is some spasm of the paraspinal muscles of the lumbar spine on musculoskeletal exam the lower extremities strength is equal bilaterally so what does that mean jeremy that means that you have some you know maybe a some arthritis in your neck here and or maybe just a a little bit of some injury from from that from that back that back thing that you told me about
[patient] mm-hmm
[doctor] okay but i think overall things look really good so you know i had them do an lumbar spine x-ray on you before i saw you and i looked at the results of your lumbar spine x-ray which showed no acute bony abnormality you know there was no fracture of your back or anything which is not surprising based on your history so let's just talk a little bit about my assessment and plan so i do believe it sounds like you have an acute disk herniation now this did happen a few months ago but it sounds like that's what you had based on the fact that you're still having symptoms
[patient] mm-hmm
[doctor] i do wan na go ahead and order a a lumbar spine mri to get a a a better look at what's going on you know x-rays really just look at the bones they do n't show us any of the soft tissue so let's go ahead and order the lumbar spine mri i wan na continue with physical therapy so i'm going to refer you to a a physical therapist through our health system
[patient] mm-hmm
[doctor] and then i also wan na go ahead and prescribe meloxicam fifteen milligrams once a day
[patient] mm-hmm
[doctor] to help with that do you have any questions about that
[patient] no questions
[doctor] now if you do have a herniated disk we can go ahead and talk about some other treatment options maybe like an epidural steroid injection to help take down some of that inflammation
[patient] mm-hmm
[doctor] it might make you feel better but we'll we'll deal with that when we get get there okay
[patient] sure
[doctor] any questions
[patient] not at this point
[doctor] okay great thank you
[patient] thank you | HISTORY OF PRESENT ILLNESS
Jeremy Adams is a pleasant 57-year-old male who presents to the clinic today for the evaluation of low back pain. The onset of his pain began 4 months ago, when he was moving boxes out of his son’s college dorm. At that time, he noted tingling in his right toes, which resolved after approximately 1 hour. After his injury, he felt as though he was unable to support his upper body weight. The patient reports weakness in his legs when carrying heavy objects. He reports a sharp pain in his lower back when he turns a certain way or rolls over in his sleep. The pain will resolve with repositioning. The patient was seen at urgent care and was referred to obtain an MRI, however he did not undergo this secondary to insurance issues. He has been utilizing Tylenol, ibuprofen, heat, and ice for pain, which does not provide relief. The patient notes the ibuprofen is slightly more beneficial than the Tylenol, however it does not relieve his symptoms. He denies upset stomach with the use of ibuprofen. Additionally, he attempted physical therapy at his gym without any relief. He denies any bladder or bowels issues, fevers, and chills.
SURGICAL HISTORY
The patient has a history of a right total knee arthroplasty 2 years ago, in spring of 2020. He states that his right knee feels 95% improved since the surgery.
REVIEW OF SYSTEMS
Constitutional: Denies fevers or chills.
Gastrointestinal: Denies bowel issues.
Genitourinary: Denies bladder issues.
Musculoskeletal: Reports lower back pain.
VITALS
Temperature: Normal.
Blood pressure: 117/56 mm Hg.
Heart rate: 68 BPM.
Oxygenation: 95% on room air.
PHYSICAL EXAM
NECK: Bony protuberance of the C5-C6. No pain to palpation of the C5-C6
MSK: Examination of the Lumbar spine: No pain to palpation of the lumbar spine. Decreased flexion and extension of the lower back. Positive straight leg raise. Spasm of the paraspinal muscles of the lumbar spine. Strength is equal bilaterally.
RESULTS
X-rays of the lumbar spine were reviewed. These reveal no acute bony abnormalities.
ASSESSMENT
Low back pain, possible acute disc herniation.
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. His x-rays did not reveal any signs of a fracture. I would like to obtain an MRI of the lumbar spine to evaluate for a possible acute disc herniation. I have prescribed the patient meloxicam 15 mg to treat his pain. He will continue with physical therapy and a referral was provided for this today. |
D2N149 | aci | [doctor] so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing
[patient] not too good
[doctor] okay how long have you been feeling not too well
[patient] about a couple of weeks
[doctor] couple of weeks tell me what's going on
[patient] i wake up with shortness of breath
[doctor] okay
[patient] i go to when i'm short of breath there i get back home and i'm again short of breath so i had a tough time dealing with this
[doctor] have you noticed any are you coughing up anything any swelling in your legs or what's going on
[patient] yeah i've been i've been coughing up i've been coughing up blood
[doctor] okay how long has that been going on for
[patient] probably three weeks or so
[doctor] okay and are you coughing a lot of blood or just a little bit of blood
[patient] i shave three to four cups a day
[doctor] wow that's a lot of blood okay are you throwing up any blood are you having bleeding in any place else or just when you cough
[patient] only when i cough
[doctor] okay have you noticed any bruising or bleeding from your teeth or anything like that or from your gums or anything like that
[patient] no
[doctor] okay any leg swelling or calf swelling or any any anything like that any recent travel history you've been on a plane or trip recently
[patient] i had some knee problem but there is no swelling but it hurts that's been going on for quite some time
[doctor] okay so that's not near the knee problem okay and have you had any have you been to the hospital or been to the emergency room or anything like that for your coughing and coughing up blood
[patient] no i tried to get an appointment in the office but they were kinda booked up
[doctor] okay
[patient] they just numb
[doctor] alright and alright no but no fevers with this so since you're here your oxygen level looks pretty good in the clinic it's about ninety four percent on pulse your pulse oxygenation so that's good are you short of breath so when you walk or you or you exert yourself you're short of breath you said right okay and have you and how how is your blood sugar been doing since this has been going on i know you're on metformin how's your diabetes been doing
[patient] not so good you know it kinda going up and down i wear this dexcom
[doctor] okay
[patient] you know after meal they spike up well over two hundred
[doctor] okay and
[patient] and morning when i get up they are around one fifty
[doctor] okay alright so it's been running a little bit high i know we checked your hemoglobin a1c last time and it was about seven . seven . i think and we had talked about you know improving your diet and improving some exercise but is this blood sugar been high and low or high and normal when you're especially in the last three weeks or has it been going on for longer than that
[patient] i would say about a month
[doctor] okay alright and how is your blood pressure been at home since you've been taking since these episodes that you've been sick are you taking norvasc
[patient] yes i am but i keep them on some days because my blood pressure has been running somewhat on the low side
[doctor] okay alright and right now it's about a hundred and twenty over seventy what how low does it go in the more when you check it
[patient] well there are sometimes in the lower nineties
[doctor] okay alright well let me let me examine you here in a second and we'll think about you know what we need to do especially with your coughing and your shortness of breath okay so nita i'm i'm examining you now let's pretend i did my exam i'm just gon na verbalize some of my findings so i can put it into my chart okay and i'll explain what those things mean so on my exam you've got no jvd there is no swelling in your neck no carotid bruits your lung exam you've got some rails and some rhonchi on on more on the right side i do n't hear any wheezing right now there is some diminished breath sounds in the right side as well on your heart exam you've got two over successolic ejection murmur you've had that in the past that's unchanged from before the rest regular rate and rhythm otherwise your belly exam is nice and soft on your extremity exam you've got one plus nonpitting edema on both of your lower extremities on your on your ankles no calf tenderness no negative homan sign so what does all this mean so basically you've got you know you've got some sort of infection or something going on in your lungs that i can hear right now the rest of your exam is pretty much stable it's unchanged from before so let's talk about what we what we should do about this so for the for the first problem with the shortness of breath the first thing i wan na do is go ahead and get a chest x-ray for you okay you've been coughing up blood i also wan na send you to the emergency department to get some blood testing done i'm worried about a blood clot or something else going on so i wan na get a cat scan of your chest as well so i'm gon na go ahead and refer you to the emergency department i'll call them and and have you head over that way they can get a chest x-ray and a cat scan and some blood work as well and then we'll evaluate why you're having the shortness of breath and why you're coughing up this blood okay and then depending on what they find you may need you know it could be as simple as a pneumonia or it could be something a little bit more serious we may have to get you know start you know depending on what you find we will get the right treatment started any questions about that or can you drive to the emergency department from here or is that okay
[patient] yeah i can bike no problem i have no question
[doctor] alright for the second problem for the diabetes since your blood sugar is running a little bit high once you get over this i'm blood sugars running a little bit high once we get you over this hump of the shortness of breath and get this diagnosed i'm gon na go ahead and order another hemoglobin a1c today we will probably increase your dose of metformin from five hundred twice a day to seven fifty twice a day so why do n't we do that and then why do n't we have we'll have the hemoglobin a1c back and then we can once you get over this illness that you're undergoing we'll we'll we'll discuss that more i'll have you come back in about three weeks to just discuss your diabetes and what our treatment plan will be for that okay
[patient] okay
[doctor] for the high blood pressure definitely hold off on the norvasc for right now let's figure out what's going what's causing this episode of shortness of breath i want some blood testing done and and once we have that under better control we can reassess your blood pressure so right now hold the norvasc and then we'll have you come back once everything is done okay
[patient] no
[doctor] any other questions or anything we know if we need to talk about today
[patient] no i'm good
[doctor] sounds good we'll get you signed out here in a second | CHIEF COMPLAINT
Shortness of breath with hemoptysis.
MEDICAL HISTORY
Patient reports history of diabetes, hypertension, and asthma. He also has a long history of knee pain.
MEDICATIONS
Patient reports taking metformin and Norvasc.
REVIEW OF SYSTEMS
Constitutional: Denies fever.
HENT: Denies bleeding gums.
Respiratory: Reports shortness of breath, hemoptysis.
Musculoskeletal: Reports knee pain. Denies lower extremity edema.
Hematologic/Lymphatic: Denies bruising.
VITALS
Pulse oxygenation: 94 percent. Blood pressure: 120/70 mm Hg.
PHYSICAL EXAM
Neck
- General Examination: Neck is supple. No JVD. No carotid bruits.
Respiratory
- Auscultation of Lungs: Some rales and rhonchi, more on the right. No wheezing right now. There is some diminished breath sounds in the right as well.
Cardiovascular
- Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur, unchanged from before.
Gastrointestinal
- Examination of Abdomen: Soft.
Musculoskeletal
- Examination: 1+ nonpitting edema on bilateral lower extremities. No calf tenderness. Negative Homan's sign.
Hematology/Lymphatic/Immunology
- Examination: No bruising.
ASSESSMENT AND PLAN
1. Shortness of breath.
- Medical Reasoning: The patient has been coughing up blood.
- Patient Education and Counseling: We discussed the importance of further testing as his symptoms could be as simple as a pneumonia or something more serious.
- Medical Treatment: I have ordered a chest x-ray, CT scan, and blood work to be done in the ER. I have instructed the patient to go into the ER immediately after this appointment and I will call ahead.
2. Diabetes.
- Medical Reasoning: The patient's blood sugar has not been well controlled.
- Medical Treatment: I have ordered an updated A1c today. He will increase his metformin to 750 mg twice daily.
3. Hypertension.
- Medical Reasoning: His blood pressure has been running low for approximately 3 weeks. I believe this could be caused by his shortness of breath. I would like to get a better understanding of the cause of his shortness of breath prior to pursuing further treatment for his hypertension.
- Medical Treatment: At this time, he will discontinue the use of Norvasc.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
We will have him follow up in about 3 weeks to just discuss his diabetes and further treatment recommendations.
|
D2N150 | aci | [doctor] alright scott so so i understand that you you had some right knee injury can you tell me a little bit about what happened
[patient] yeah i was trying to go out and play some pickup soccer games over the weekend and went to go plank kick the ball and and just felt a pop in my right knee
[doctor] okay and and how long ago did that happen
[patient] about three days ago
[doctor] three days okay and when did you notice any swelling anything like that
[patient] it it's swollen some some of that swelling has gone down
[doctor] okay
[patient] but it it mainly just it it feels like that i just i ca n't my knee is just not as functionally it's not moving as well as what it used to be it seems to be a little limited
[doctor] okay alright and then so how's the pain with your knee on a scale of one to ten one being the least pain ten being the worst pain how's how's it been ranging
[patient] it's somewhere between six and seven right now it's about four or five with some of the swelling going down
[doctor] okay alright and did you take anything at all to relieve the pain
[patient] anti-inflammatories
[doctor] okay alrighty and did that help
[patient] yeah the ibuprofen helped a little bit but i'm on it pretty on a pretty regular basis right now
[doctor] gotcha okay now tell me are you able to bend or straighten your leg ever since then
[patient] i can bend it but it hurts towards the end of the motion and i can straighten it but it does n't it feels like i have to help get it straightened
[doctor] okay alright and then how about you able to bear any weight on it or walk on it at all
[patient] i can still bear weight on it but it feels just really loose it it does n't feel normal
[doctor] gotcha okay alright well let's go ahead and take a look at your knee here real quick before i take a look at your knee here i'm gon na do a physical exam and in terms of your gait here i did notice that you do have a marked limp on your looks like it's your right leg upon ambulation so let me go ahead and take a look at that right knee real quick i do appreciate some significant effusion in the right knee just a slight bit of ecchymosis let me just feel around here scott how does that feel does that hurt when i kinda press on that there
[patient] a little bit of pain there not not really bad it's it feels like it's just more on the inside of my knee
[doctor] yep okay so you definitely feeling some a little bit of pain to palpation at the medial joint line now i'm gon na have you lie on your back and also i'm gon na do some maneuvering here of your leg i'm gon na do a real quick test on you here okay alright how does that feel
[patient] just feels just feels loose it hurts when you pull it at the very end
[doctor] okay sorry about that alright so you're definitely having some difficulty with some passive range of motion here and you're lacking a few degrees of terminal extension to about a hundred and fifteen degrees as well as lacking about maybe twenty to thirty degrees of terminal flexion on the secondary secondary to the pain here and you do have a positive lachman exam so one more thing i wan na take a look at real quick i'm gon na take a look at your toes here real quick very good so neurovascularly your bilateral lower extremities are intact and it looks like you have a muscle strength of a five out of five so scott you know based on my examination here your right knee injury is really suggestive of anterior cruciate ligament tear and you've heard of it probably even heard as acl tear sometimes especially when a lot of people do sports and they injure their knee that that can happen so my plan for you though is i wan na i wan na go ahead and order an mri because i wan na evaluate the integrity of that acl now you may need surgery but we'll we'll first take a look at that mri result and reevaluate and reevaluate that first but in the meantime i wan na go ahead and order some anti-inflammatory medication meloxicam fifty milligrams a day it's gon na help reduce that swelling and the pain and then i want you to go ahead and ice the knee if you need to if you're still seeing some swelling and some pain you can go ahead and use ice as well but i definitely would like for you to moderate your activities so i would like for you to wear a knee immobilizer and then also use crutches when you walk around just to help you a little bit so not to put too much stress and strain on that knee does that sound like a plan
[patient] it it does now well i need to limit my work activities i i typically sit behind a desk but it's not been very comfortable sitting here lately
[doctor] yeah definitely so yeah so you you can limit the activities for sure in terms of your work activities i know if you sit too long sometimes it can be painful because you do need to move that leg a little bit so it does n't lock up so i i would like for you to you know do do some slight activities not enough to stress your legs but definitely move move them a little bit every now and then so it does n't lock up on you okay
[patient] okay
[doctor] alright i do want you to i know you are i know you actually jog often so i want you to just slow that down for a bit no jogging for a while until we get you know results of your mri till we figure out what we what we are gon na be doing okay
[patient] okay
[doctor] alright and how's your dog you has it been jogging with you before this incident
[patient] how's just how's my dog or how is my job
[doctor] your your dog
[patient] my my my dog is okay
[doctor] good
[patient] is doing really well and and he enjoys still playing around outside but looks like wo n't be able to do that for a little bit
[doctor] very good alright well i'm gon na go ahead and have the nurse take you to the scheduler to get your mri and i'll get back with you as soon as we get the results of that
[patient] okay sounds good thank you
[doctor] thank you | CHIEF COMPLAINT
Right knee injury.
HISTORY OF PRESENT ILLNESS
Scott Miller is a pleasant 36-year-old male who presents to the clinic today for the evaluation of a right knee injury. The injury occurred 3 days ago, when he was playing pickup soccer games and felt a pop in his right knee. He reports swelling at the time of the injury, which has improved. The patient states that his knee is not as functional or moving as well as it used to be. He rates his pain level as a 6 to 7 out of 10 currently and a 4 to 5 out of 10 when the swelling decreases. The patient has been taking ibuprofen on a regular basis, which provides some relief. He states that he is able to bend his knee with pain towards the end of this motion; however, when he goes to straighten his knee, he feels like he has to help it straight. The patient adds that he is able to bear weight on his right knee, however it feels loose and does not feel normal.
SOCIAL HISTORY
The patient works at a desk.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right knee pain.
PHYSICAL EXAM
GAIT: Marked limp in the right leg upon ambulation.
MSK: Examination of the right knee: Significant effusion. Slight ecchymosis. Pain with palpation at the medial joint line. Difficulty with passive ROM. Lacking a few degrees of terminal extension to 115 degrees. Lacking 20-30 degrees of terminal flexion secondary to pain. Positive Lachman's test. Muscle strength is 5/5. Neurovascular intact distally.
ASSESSMENT
Right knee pain, possible anterior cruciate ligament tear.
PLAN
After reviewing the patient's examination findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate the integrity of the ACL. I have prescribed the patient meloxicam 15 mg a day to reduce swelling and pain. We discussed that the patient should utilize ice and activity modification to reduce swelling and pain. I recommended that he wears a knee immobilizer and use crutches when he is ambulating. He will avoid jogging until we have the results of his MRI.
INSTRUCTIONS
The patient will follow up with me once the MRI results are available for review and further discussion. |
D2N151 | aci | [doctor] alright teresa i see here in your chart that you seem to be experiencing some elbow pain could you tell me where it hurts
[patient] yeah so it's hurting on the inside of my elbow
[doctor] mm-hmm
[patient] and when i i i've been doing some pottery i've been creating you know i have a pottery wheel and i've been i love my pottery and for my son's birthday i've been making a a ceramic bowl and i'm gon na paint it and i have to do some real full decorations but i've really been working on it a lot and my gosh this is hurting and i ca n't work on it right now because it's hurting so much
[doctor] i am so sorry so i mean that's really cool that you do parttery it's something that i've wanted to pick up you know but i do n't know that i have those skills yet does the pain radiate down your arm or up your shoulder or anything
[patient] yeah it does down my arm and along that inside of my arm
[doctor] okay so the medial aspect okay have you did you hit it on anything
[patient] no not that i recall
[doctor] okay and have you ever injured your elbow before
[patient] no i have n't
[doctor] okay alright so on a on a scale of one to ten with ten being your arm is actively being sought off by a chainsaw how bad is the pain
[patient] well i'd say it's about a seven
[doctor] wow that's pretty bad does it keep you up at night
[patient] yes it really does it's you know if i roll over and it it it just wakes me up
[doctor] okay have you done anything to relieve the pain
[patient] well i have been taking some ibuprofen but that is n't really helping
[doctor] okay and have you tried anything like ice or heat or anything else
[patient] i tried a little bit of ice at first
[doctor] mm-hmm
[patient] but and it's just it's been hurting for about four days now
[doctor] okay
[patient] did n't getting better
[doctor] okay okay so it's probably it do you think it's getting worse
[patient] well it's just not getting better
[doctor] okay no i understand okay so i know that you also have like a history of hypertension and that we have you on ten milligrams of lisinopril have you been checking your blood pressures regularly
[patient] yeah you know what i remember too i mean they they have been pretty good one teens to one thirties
[doctor] okay alright and okay do you think that you've been good about taking your medications do you usually take them everyday
[patient] yeah pretty much i i i you know set an alarm for that lisinopril
[doctor] awesome that's great alright and so i see that you also we are treating you for diabetes as well and that we have you on five hundred milligrams of metformin twice a day how about that have you been taking that regularly
[patient] well sometimes i forget i mean having a medication twice a day you know sometimes i'm out doing stuff and i just forget to take it
[doctor] okay
[patient] and plus i kinda have a sweet tooth so you know sometimes they're a little bit higher you know like one fifty to one seventy so
[doctor] okay alright so when you say a sweet tooth what are we talking about there
[patient] i love to bak also besides my ceramics i'm really big and baking and i like to make cakes and and take them to you know parties and get togethers you know family get togethers and i like to make senna rules too i've been doing that since i was very young so i kinda noticed that
[doctor] okay cinnamon rolls can be kind of hard like do you for your cakes do you do you use fondant you know to like do any of the decorations
[patient] no i i mine are just pretty basic they're not overly fancy
[doctor] okay
[patient] simpon rolls i got that recipe out of a southern living magazine
[doctor] oof
[patient] a long time ago and
[doctor] so you know it's good
[patient] yeah
[doctor] alright well so i totally understand like baking and like the excitement of being able to give those to your family but we maybe wan na start cutting down on eating and taste testing ourselves is do you think that's something we could manage
[patient] yeah i know i need to get better on it i probably could use maybe a refresher on just managing what i should and should n't eat how like if i need to combine a protein you know if i do eat something a little bit sweet maybe pling a protein or something with it
[doctor] mm-hmm yeah that sounds like a
[patient] had some friends tell me something about that
[doctor] yeah that sounds like a great idea and i think if that's something that we can maybe discuss to get you in contact with someone who can offer you someone with a degree that can offer you some really good advice you know i do n't wan na as much as it's really helpful to have friends i do wan na be able to give you like a source of truth right
[patient] yeah i i had a diabetic consult a long time ago but yeah it it would be nice to see a dietitian again and go over those and maybe there is some new stuff too
[doctor] a hundred percent yeah you know like i one of the things that i struggle with is like are eggs good for you or bad for you you know like with cholesterol i feel like it changes every other year or something like that so you're right there may be some pieces of information that we do need to update and and you know over a fresh of course would n't hurt but if you do n't mind i'm gon na go ahead and start my physical exam i'm gon na call out my findings and just go let me know if you have any questions or if anything sounds anything that you you want me to expand on further but this is just for the recording sake so we can get everything documented okay
[patient] yeah and can i ask you what word what were my vital signs can you show me what my vital signs were
[doctor] yeah that's uh uh that's a really good question so our big and favorite one is gon na be your blood pressure right so you're right like we are seeing some some definite improvement today it was one twenty over seventy and honestly that's a great place to be so that tells me that your medication is working and that maybe we can start to evaluate a bit more your respiratory rate is completely normal so i see it here as eighteen that's wonderful you are not running a fever so ninety seven . nine and you're honestly that's within like a good enough range for me you're satting pretty well your oxygen saturation is a hundred percent again so that means that you're not experiencing any kind of difficulty getting in that oxygen to the rest of your body i do wan na say that you know pain is one of the vitals that we worry about and you're saying that at it's worst your the pain in your elbow is a seven out of ten so that's something that i'm gon na evaluate and then your pulse rate seems to be appropriate as well so those are all great do you have any questions about that so far
[patient] no that sounds good yeah i was just curious
[doctor] yeah
[patient] checked it in a while so
[doctor] mm-hmm i do wan na say that like looking at your the weight we do see like maybe a five pound increase from the last time that you were here but that's completely normal right to be able like to fluctuate you know give or take five pounds so i'm not i'm not i'm not like seriously worried about it but if we do come back and notice an additional five pounds then we might have to start talking about like actually you know what let's do that right now what kind of exercise regimen are you on
[patient] well i do go for some walks in the evening i try to get one in on the morning too
[doctor] mm-hmm
[patient] so not a whole lot other than that because i'm busy with my pottery or baking so but i do try to get out and walk daily
[doctor] okay that's awesome so like how about about how long are your walks
[patient] well i just walk around the neighborhood there is you know the sidewalks and there is kind of a little bit more of a nature type area that goes across the bridge and so it's probably you know maybe one to two miles a day
[doctor] wow that's intense i was not expecting that number that's awesome okay alright so maybe this five pounds is muscle we're gon na go for it okay but thank you but that's some really important information but i'm gon na start your physical exam now okay
[patient] okay
[doctor] alright so i know that you said that you are experiencing elbow pain could you tell me is it your left or your right elbow
[patient] it's my right
[doctor] okay alright right elbow when i touch it does it hurt on the inside
[patient] yes it does
[doctor] okay so moderate tenderness at the medial epicondyle when you turn like when you turn your wrist is if you're trying to open a door knob do you experience pain
[patient] no not really
[doctor] alright so turning out no pain but when you turn your wrist inwards do you have any pain
[patient] yeah
[doctor] okay so pain with resisted pronation of right forearm when you rest your arm on a table with the palm side up alright i want you to raise your hand by bending the wrist do you experiencing any pain
[patient] yeah that hurts
[doctor] alright alright so when you are when i'm pressing here and like flexing your wrist are you experiencing any pain
[patient] yes
[doctor] alright pain with flexion and when bending the wrist alright when i listen to you you know i'm just gon na check your heart and lungs everything sounds sounds good no murmur no rub no gallop your lungs are clear bilaterally to bilaterally to auscultation i'm not noticing any rash for your at your elbow i do n't notice any bruising any swelling we do wan na note that tenderness but otherwise there is no discoloration no lesions so that's good your pulses and are equal bilaterally and i think i think we have an idea of what we are dealing with here okay so i'm gon na go ahead and give you my impression and plan for your your first problem like your primary problem that you are here for is right elbow pain it's consistent with medial epicondylitis and that it just means it's pain caused from overuse and damage to the tendons in your arm what we are gon na do is rest it i'm gon na order a sling for your right arm and you can wear this while you're awake well i want you to apply ice to your elbow for twenty minutes three times a day i'm going to i'm gon na ask you to take six hundred milligrams of ibuprofen that's three pills every six hours with food and you can take that for one week i know it's really important that you said that you have something that a gift that you wan na make for your son but we're gon na hold off on pottery for the next couple of weeks just to give your arm a chance to heal you know like it's awesome that you wan na be able to do these things for your family but sometimes you know your body is not where your where your where your heart is like where your heart and your head are right and then so
[patient] i'll i'll just let him know that that i maybe i'll take a picture of what i have so far
[doctor] absolutely that's awesome and so it'll be like a a movie like coming soon to a shelf near you that's great for your second problem right we have this longstanding diabetes i want to increase your metformin to a thousand milligrams twice a day i know that you're saying you're having a hard time keeping up with that so i want you to do a good job of like checking and recording your blood sugars every day i do need you to follow up with me in a couple weeks i also wan na order something called an a1c since you are having a hard time with like the blood like the blood sugars everyday an a1c will give me a more accurate picture of like a longer period of time and then we might need to evaluate like what are what other options that we have if your sugars if we ca n't get them a bit more under control i do want you to follow up with me in a couple of weeks about the about your diabetes and for your third problem of hypertension we're just gon na continue you on your lisinopril at ten milligrams that's it seems to be doing it's job i'm really i'm really glad about that and it's probably due to the walking that you're doing i forgot to mention for your diabetes we are gon na i'm gon na recommend a a referral to diabetic counseling that way you can get like a bit more information on like the steps that you can take to help you with that
[patient] i was gon na ask you how about my x-ray the x-ray of my elbow how did that look
[doctor] your x-ray honestly looks great in that i do n't see any kind of fracture or bony abnormality so that's what makes me think that this is like a tendon related thing right so in reviewing your x-ray like it it does support the the the assessment and plan that i have given you i
[patient] okay
[doctor] do you
[patient] just true
[doctor] yeah absolutely i do think for your your primary problem the elbow that we might wan na get put you in some physical rehab if the problem is taking a little longer to heal but we'll discuss that at your next visit here okay
[patient] okay
[doctor] alright no problem any other questions
[patient] nope
[doctor] alright thank you for keeping me accountable | CHIEF COMPLAINT
Right elbow pain.
HISTORY OF PRESENT ILLNESS
Teresa Sullivan is a pleasant 33-year-old female who presents to the clinic today for the evaluation of right elbow pain. Her pain began 4 days ago, without any improvement. She denies any specific injury; however, she has recently increased her usage of a pottery wheel in creating a bowl for her son. She is currently unable to work with the pottery wheel secondary to pain. Her pain is in the medial aspect of her elbow. She notes it radiates medially down her arm as well. The patient rates her pain level as 7 out of 10 at its worst. She reports the pain wakes her at night if she rolls over. She denies ibuprofen or ice provide pain relief. The patient denies any previous elbow injuries.
The patient has a history of hypertension. She states she has been checking her blood pressures regularly. She adds that her blood pressures have been in the 110s to 130s range. She affirms she is taking lisinopril 10 mg daily and denies missing doses.
Regarding her diabetes type 2, she reports she sometimes forgets to take metformin 500 mg twice daily. At times, her blood sugar levels range from 150 to 170 mg/dL. She states that she has a sweet tooth and indulges in home baked goods. For exercise, she walks in the evening and in the morning. She walks 1 to 2 miles per day around her neighborhood.
The patient enjoys working with ceramics as well as baking cakes and cinnamon rolls for family gatherings.
MEDICAL HISTORY
Patient reports history of hypertension and diabetes type 2.
MEDICATIONS
Patient reports taking lisinopril 10 mg and metformin 500 mg twice daily.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right elbow pain.
VITALS
Blood Pressure: 120/70 mmHg.
Pulse Rate: Appropriate.
Respiratory Rate: 18 breaths per minute.
Oxygen Saturation: 100% on room air.
Body Temperature: 97.9 degrees F.
Pain Level: 7/10 at its worst.
Weight: 5 lb increase since last visit.
PHYSICAL EXAM
CV: No murmurs, gallops or rubs. Pulses are equal bilaterally.
RESPIRATORY: Normal respiratory effort, no respiratory distress. Lungs are clear bilaterally to auscultation.
SKIN: No rash or lesions.
MSK: Examination of the right elbow: Moderate tenderness at the medial epicondyle. Pain with resisted pronation of the right forearm. Pain with flexion and bending the right wrist. No bruising or swelling. No discoloration or lesions.
RESULTS
An x-ray of the right elbow was reviewed today. It demonstrated no evidence of any fractures. No other abnormalities are noted.
ASSESSMENT
1. Right elbow pain, consistent with medial epicondylitis.
2. Diabetes type 2.
3. Hypertension.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with her regarding her current symptoms. I have explained to her that her elbow pain is consistent with medial epicondylitis and was most likely caused by overuse and damage to the tendons in her arm. I have recommended that we treat the patient conservatively. The patient will wear a sling on her right arm while she is awake to provide increased support. I advised her to ice her right elbow for 20 minutes 3 times per day. She will take ibuprofen 600 mg every 6 hours with food for 1 week. I have also advised her to hold off on creating pottery for the next 2 weeks to allow her arm to heal. If the patient continues to experience persistent elbow pain, we may consider formal physical therapy at her next visit.
I have encouraged the patient to check and record her blood sugars every day. I will increase her metformin to 1000 mg twice a day. The patient and I discussed the importance of her taking her medication on a regular basis twice a day. I have also recommended that she be referred to diabetic counseling for more information on the steps she can take to manage her diabetes. I will also order a hemoglobin A1c test for a more accurate assessment of her long-term blood sugar levels.
The patient’s hypertension is currently controlled with medication and exercise. I have instructed her to continue taking lisinopril 10 mg. I also encouraged her to continue with her walking routine.
All questions were answered.
INSTRUCTIONS
The patient will follow up with me in 2 weeks to review the results of the hemoglobin A1c test and discuss her progress. |
D2N152 | aci | [doctor] good morning noah tell me a little bit about why you are here today
[patient] hi document i'm i'm just had you know the back pain you know and i've i've had it for you know about a week and
[doctor] oh
[patient] you know i mean i tried some you know i mean medications but you know some over the counter stuff but it does n't go away
[doctor] okay can you tell me a little bit more about it how did it start or how did it do you remember injuring yourself
[patient] no not really i mean i was just like you know i guess i one day i mean i just twisted you know on my left and maybe i mean i might have picked something up
[doctor] okay
[patient] so i mean at that time i mean there was this pain but i you know it went away you know and i thought that was you know that was you know the end of it but you know i mean after you know a few hours you know it's it kinda it came back
[doctor] okay
[patient] it's been there since then you know
[doctor] okay and is it anywhere in specific is it in the middle of the back across the whole low back or on one side or the other
[patient] i think it's more towards you know right in the middle maybe on the lower side and nothing on the you know i mean it sometimes it goes back you know maybe having troubles with the left eye i suppose but i mean it's aggravated you know when i you know when i do some you know maybe i'm a sudden movement to the left
[doctor] okay and that's when you get the pain more maybe located in the center but it goes across to the little back and i on the left side and i also heard you say you know if you twist suddenly that makes it worse is that correct
[patient] it makes it worse it makes it worse i mean yeah
[doctor] now you know i was looking at your records and i know you have that history of diabetes and i have n't seen you a while for a follow-up for that how you've been feeling
[patient] i mean been okay i mean i take my meds
[doctor] okay
[patient] and i try to still have sugar but you know i mean i you know you know i mean whenever i get the chance i mean i you know i exercise but you know i mean that's about it
[doctor] okay so you're on
[patient] mm-hmm
[doctor] yeah i think i think you're on that metformin twice a day
[patient] yeah
[doctor] yeah okay
[patient] yes
[doctor] do you test your blood sugar at home in the mornings
[patient] yeah i mean i try to
[doctor] okay
[patient] most of the morning but sometimes i mean i go skiing yeah
[doctor] and how have those numbers been
[patient] they bumped towards i mean bit towards the higher side i mean i must have been
[doctor] okay
[patient] you know but
[doctor] well if
[patient] yeah
[doctor] yeah if i remember right your family do n't they own that that bakery down on the corner of main street and did n't they own that
[patient] yeah thank you
[doctor] and how do you do you stay away from those i i got ta be honest i love i love the cakes and donuts they make those are delicious
[patient] yeah i try to
[doctor] okay
[patient] but i mean you know they they you know i have to visit them and you know i end up you know i mean getting some stuff but it's not that much
[doctor] okay
[patient] but it's been i try to contain it you know
[doctor] well let me so we're gon na have to watch that and i'll come back and we'll talk a little bit about the diabetes but let's go ahead and do that i do n't wan na do a a a quick physical exam on you i'm gon na look in your eyes here and so let me quickly look in your ears
[patient] i see
[doctor] okay that looks good and any let me let me listen to your lungs okay your lungs are clear and your heart it's a regular rate and rhythm that's all good as we go through that now i want you to sit up here i'm gon na press down your back starting at the top and any pain up top no
[patient] no
[doctor] okay and then once i get down here and around that low back i wan na press in the center first does that cause you a lot of pain
[patient] yeah
[doctor] yeah okay
[patient] yeah that that's the spot
[doctor] okay and if i come over here to the right no
[patient] not that much you know
[doctor] okay so and then on the left hand side if i push down here kind of into your butt
[patient] yeah
[doctor] yeah okay
[patient] yeah
[doctor] lay back on the stretcher for me for a second i'm gon na go ahead and and lift your legs for me or i'm gon na go ahead and lift your legs for you just relax i'm gon na start here on the right side when i lift that right leg up does that cause you significant pain or any pain at all
[patient] a little a little bit
[doctor] okay let me come around let me lift up the left side if i lift that up does that cause
[patient] yeah yeah yeah that's that's
[doctor] yeah
[patient] still get tender yeah
[doctor] i can see that gritts on your face so okay that's good and you know as i look at your lower extremities there is no pain or numbness or tingling in your feet or anything like that
[patient] hmmm no
[doctor] okay okay so lem me talk a little bit about my impression and plan so for that low back pain i believe you have a musculoskeletal low back strain i'm going to order a low back x-ray so we'll order that and get that done as an outpatient i do n't expect to see anything significant but it's gon na tell me how those joint spaces look and if you know if we're dealing with any disk issue but that will be the start of it and i'm also gon na order some physical therapy two for two reasons to help with a little bit with the pain but also strengthen some of the muscles there in the back so those are the two things that we are gon na do now i want you to take take four hundred milligrams of ibuprofen you can take that occasionally with some tylenol when the pain gets more severe up to about three times a day i'm gon na also give you a prescription for some flexeril that's a muscle relaxant and i want you to take one of those once a day every evening but be careful if you're doing any strenuous or hazardous activities such as driving after you take those now for your diabetes my impression is that your diabetes is is under control i noticed that we do n't have n't had a a1c for almost five months so i'm also gon na order an a1c so we can find out where we are with that continue with your diet and exercise we know that's really important and then continue with your metformin i'm not gon na make any changes today but we'll go ahead and look at that once i get that results of that a1c do you have any questions for me
[patient] yeah can i still go to the bakery
[doctor] i would yes it's nice for you to go to the bakery but you ca n't have any donuts i'm no i you just really need to watch that intake of of anything that you might get at the at the bakery so just just be careful with those carbohydrates those sweets that you're taking as we go through your day it's occasional occasional one perfectly fine but on a routine basis we need to watch that
[patient] right and how soon should i you know check my blood sugars i mean what's a good you know
[doctor] yeah i that's a great question i'm really glad you asked that i would prefer that you're taking your blood pressure every morning the first thing you get up when you get up in the morning that's gon na give me a good idea and so if you can do that the first thing in the morning and keep a record of it you know i know your glucometer keeps a record of it but if you can write them down and once we get that a1c that's gon na give me a little more guidance on how to deal with your blood your diabetes
[patient] right do you think would i need to see you know a pain doctor or you know
[doctor] not yet let's let's get the that's a great question i may end up referring you to a a pain doctor for that low back pain but i really would like to start with some of the diagnostics first let's get an x-ray and if there is you know any question of that x-ray and the pain continues i'm gon na go ahead and maybe order a cat scan and then at that point in time we can refer you to a pain doctor if we're still having significant pain
[patient] sounds good
[doctor] okay thank you i'm gon na send my nursing to see you and we'll get you out the door
[patient] thank you
[doctor] take care
[patient] that one is a follow-up mm-hmm | CHIEF COMPLAINT
Back pain.
MEDICAL HISTORY
Patient reports history of diabetes.
SOCIAL HISTORY
The patient's family owns and runs a bakery.
MEDICATIONS
Patient reports taking metformin twice daily.
REVIEW OF SYSTEMS
Musculoskeletal: Reports back pain.
Neurological: Denies numbness or tingling in feet.
PHYSICAL EXAM
Eyes
- Examination: No redness, discharge, or icterus.
Ears, Nose, Mouth, and Throat
- Examination of Ears: Auditory canal and tympanic membranes are clear.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate and rhythm.
Musculoskeletal
- Examination: No pain to palpation of the upper back. Pain to palpation of the midline of the lower back, especially on the left. No pain to palpation on the right lower back. Mildly positive straight leg rise on the right Positive straight leg rise on the left.
ASSESSMENT AND PLAN
1. Low back pain.
- Medical Reasoning: I believe he has a musculoskeletal low back strain. I do not expect to see anything significant on x-ray, but we will obtain one for further evaluation of any possible disc issues.
- Patient Education and Counseling: We discussed his diagnosis at length today. I explained that physical therapy can help with the pain, but also strengthen some of the muscles in the back. I explained that he needs to be careful while taking medications, such as an overuse of muscle relaxers if he is doing any strenuous or hazardous activities such as driving.
- Medical Treatment: Low back x-ray ordered. Referral to physical therapy provided. He will take 400 mg of ibuprofen up to 3 times per day. Tylenol can be used for severe pain. Prescription for Flexeril also provided.
2. Diabetes.
- Medical Reasoning: His diabetes is currently under control.
- Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. I encouraged him to try an avoid foods high in sugar. He asked many questions and I feel he is confident in the plan at this point.
- Medical Treatment: Hemoglobin A1c ordered as he has not had an updated one in almost 5 months. He will continue with his diet and exercise. Continue current dose of metformin for the time being. The patient will be checking his blood sugar in the morning and will log this information for me.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N153 | aci | [patient] i hope i did n't hurt it again
[doctor] hi gregory how are you i the medical assistant told me that you injured your knee
[patient] yeah yeah i heard it stepping off a curb
[doctor] how long ago did that happen
[patient] about two and a half weeks ago
[doctor] two and a half weeks ago and what what knee is bothering you
[patient] the right knee the outside of my right knee
[doctor] the outside of your right knee
[patient] yeah
[doctor] okay and did you actually fall down when this happened or
[patient] no i just sorta turned over my ankle
[doctor] okay
[patient] to the outside and i thought my ankle was the thing that was gon na hurt most but after the ankle soreness went away the only my knee hurt and it sort of clicks when i walk
[doctor] and no okay so now it clicks when you walk okay does it hurt when you walk
[patient] no unless i stand on one foot for an extended period of time like leaning my foot up against the wall
[doctor] okay
[patient] then i feel like it's locked and then i sort of have to ease into walking again
[doctor] okay and what have you taken for the pain
[patient] really nothing
[doctor] okay
[patient] ibuprofen but i'm not a big pill taker so i sort of sucked it up and
[doctor] does the ibuprofen work
[patient] at night you know during the day i'm more active so it it really does n't impact it because i just work through it but at night it does help me to settle down and sleep better
[doctor] does your knee hurt when you're just resting and sitting there
[patient] no when it's up it's fine when it's down on the floor with my foot flat it's fine it does hurt when i rest it on my heel
[doctor] okay and are you able to do things like bending or things like that
[patient] a full squat that's when i feel the most clicking like if i go all the way down to a full squat like a catcher that's when i feel the most clicking but otherwise no there is no pain it's just the clicking and i'm fearful that that's an injury of some type
[doctor] okay alright now you said squats are you are you active are you doing like burpees going to
[patient] no i ride the bike
[doctor] okay
[patient] i ride the bike i ride the bike which i'm not doing now peloton inside for the winter i do have a winter bike though
[doctor] okay alright well i have a peloton who is your favorite instructor
[patient] i i actually do n't have a favorite instructor i have more favorite rides
[doctor] okay what kind of rides do you like
[patient] i like rock music and regain music rides so whoever is doing those in a began or a medium content i'm cool with
[doctor] i ca n't picture you as a regade person so that's interesting to know okay alright and any numbing or tingling in your foot at all
[patient] yes but not from the knee injury i broke my foot my second toe on my right foot and i have numbness depending upon the shoe i wear
[doctor] okay when did you break your toe
[patient] i've broken it three times over the last ten years so it's just something that's a an annoyance but it was n't caused by this injury
[doctor] okay so you do have some numbing and tingling but it's not new
[patient] right correct
[doctor] alright alright well let's just go ahead and i'm gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee
[patient] no not physically
[doctor] okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt
[patient] only when you pull it to the outside
[doctor] okay
[patient] from my my foot when you pull it to the outside that's the only time it hurts
[doctor] okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i looked at the results of your knee x-ray and it does n't show any acute fracture or bony abnormality which is not surprising based on your injury so let's just talk a little bit about you know my assessment and my plan for you so i think you do have a a lateral a lateral collateral ligament strain based on your exam findings and this this type of injury essentially can be healed by itself you know i do n't think we're gon na need to refer you to surgery or anything like that i want you to go ahead and i'm gon na prescribe meloxicam fifteen milligrams once a day i do wan na go ahead and refer you to physical therapy because if we strengthen up those muscles and areas around that injury then that will make your knee stronger it help prevent future injuries are you able to ice it at all during the day now you said you working you work in sales so you said you're home
[patient] yeah i actually i'm at home so i can ice it and i have been icing it
[doctor] okay
[patient] i mean twenty on twenty off at least four times a day
[doctor] okay and so does that help at all
[patient] it's it it makes it feel better in the morning when i first go to my desk and at the end of the day before bed you know i take ibuprofen so i do n't have swelling overnight but honestly i have a pretty decent threshold for pain so it's not good it's not changing it by much
[doctor] okay do you feel like your symptoms are getting worse or better i think i think pretty much for the last two weeks they've remained about the same the the only time i feel like they get worse is when i exert myself doing up and down like gardening in the yard or moving pots
[patient] and stuff outside that's the only time i felt like it got any worse but nothing to the point where it stayed worse
[doctor] okay alright well let's go ahead and refer you to physical therapy if you're still having pain then we might have to consider an mri
[patient] okay
[doctor] any questions about that
[patient] no
[doctor] okay alright well it was very nice seeing you today call me if you need anything
[patient] i will
[doctor] okay bye
[patient] bye | HISTORY OF PRESENT ILLNESS
Gregory Price is a pleasant 68-year-old male who presents to the clinic today for the evaluation of a right knee injury. The onset of his pain began 2.5 weeks ago, when he stepped off of a curb and turned over his ankle. He locates his pain to the lateral aspect of his right knee. The patient also reports clicking with ambulation. He denies any pain with ambulation unless he stands on one foot for an extended period of time. The patient also reports locking of his knee with prolonged standing. He notices pain when he is resting his foot on his heel. He denies any pain at rest and elevated, or when his foot is flat on the ground. The patient states that he is more active during the day, which does not impact his knee pain. He adds that he is able to perform a full squat without pain. The patient reports numbness and tingling in his right foot, however this is not new. The patient has been taking ibuprofen, which provides him with relief at night. He has also been icing his knee 4 times per day, which provides him with relief in the morning and at the end of the day.
MEDICAL HISTORY
He states that he has fractured his 2nd toe 3 times over the last 10 years.
SOCIAL HISTORY
The patient works in sales. He rides a bike for exercise.
REVIEW OF SYSTEMS
Neurological: Positive for numbness and tingling in his toes on his right foot from prior injury.
PHYSICAL EXAM
CV: >Palpable dorsalis pedis and posterior tibialis pulse.
MSK: Examination of the right knee: Slight edema. Slight effusion. No pain with palpation of the right lateral knee. Positive varus test. Full ROM. Negative Lachman's.
RESULTS
4 views of the right knee were taken. These reveal no evidence of any fractures, dislocations, or bony abnormality. No other abnormalities are noted.
ASSESSMENT
Right knee lateral collateral ligament strain.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any acute fractures or bony abnormality. I have recommended that we treat the patient conservatively with formal physical therapy to strengthen his right knee. I have also prescribed the patient meloxicam 15 mg to treat his pain. If his pain does not improve with physical therapy, I will recommend obtaining an MRI.
|
D2N154 | aci | [doctor] hi dennis how are you today
[patient] good
[doctor] so what what brings you into the office i do n't believe i have ever seen you before here
[patient] the i'm training for a triathlon and the back of my heel hurts typically after a workout or when i first get up in the morning it will really hurt in the back of my heel all the way up into my calf
[doctor] okay now tell me a little bit about this triathlon training what do you are you are you running far are you tell me kind of how you work out for that today
[patient] i i will run about ten klometers
[doctor] okay
[patient] in the morning at lunchtime i try to get on the bike for about forty five minutes to an hour
[doctor] okay
[patient] and then in the evening i go to the aquatic center and i jump in the pool and swim for about another thirty minutes to an hour
[doctor] wow that's that's a that's an aggressive campaign to get there so really hope you get that triathlon in so you're how many days a week does this occur that you're training
[patient] i i do that five days a week on the weekends i kinda alternate between you know a long run and a long bike do n't really do a long swim but
[doctor] okay
[patient] i i just swimming on those other five days and i take one day off
[doctor] okay on your running days or when you do the running tell me a little bit about your stretching routine do you are you aggressive stretchers you do not stretch at all i know people that do both
[patient] yeah i do n't i do n't stretch at all i do n't have time for that
[doctor] okay and i'm assuming that with the bicycle either you do n't really work the lower legs to get them stretched out you just jump on and go correct
[patient] yeah
[doctor] okay
[patient] yeah you know i you know when i first start off i go slow until i'm warmed up and then i
[doctor] okay tell me a little bit about the pain is you said it it's after the activity but it you when you first wake up in the morning it it's it's there also
[patient] yeah when i first get out of bed it's just it just feels really tight and almost like it's tearing and i after i been walking around for about ten or fifteen minutes it eases up a little bit but if if i ever sit down for any extended period of time and then try to get back up it's really sore again
[doctor] okay
[patient] or
[doctor] no go ahead go ahead
[patient] or after a lot of activity it'll get sore too
[doctor] okay okay i'm sure this is impacting that ability to to really focus on your training uh as you're going with that with that type of a pain so lem me go ahead and let's let's take a look at your your and your lower extremities here and yeah okay so roll up your pants yeah okay good now does your left leg hurt at all do you get that severe pain or is it mainly on the right
[patient] no it's mainly just on the right
[doctor] okay okay so i'm gon na just hold your leg here and i want you to take your your foot and ankle and i want you to go ahead and just pull your your toes up towards you does that create some pain when you do that
[patient] yeah a little bit
[doctor] a little bit okay now i'm just gon na hold your foot up and i want you to push against me and does that hurt
[patient] yeah that hurts a little bit too
[doctor] yeah okay okay roll over here on my my stretcher for me and i want you to dangle your your feet over the edge and what i wan na do is i just wan na i'm gon na squeeze your left calf first and when i do that does that hurt on your left side
[patient] no
[doctor] okay
[patient] no
[doctor] and i'm gon na squeeze on the right side anything there
[patient] no
[doctor] okay okay well that's good your your thompson test is negative that's a really good finding and i just wan na continue pressing here on your right from your heel when i squeeze your heel does that cause significant pain at all
[patient] yeah
[doctor] yeah okay and if i come up a little bit further as i i run up that achilles tendon does that hurt
[patient] that's real tender
[doctor] yeah okay okay great not great so yeah go ahead and sit up for me so dennis my diagnosis is achilles tendinitis and it's really from overuse when we see this frequently when somebody starts to you know get in and train aggressively for an event i'm unfortunately i'm gon na have to ask you to stop training for a a week or two i know that's concerning but i really want this to heal before we move into that next phase i did n't ask you about medication but i'm assuming whatever you were doing was n't working significantly so what i'd like you to do is take some ibuprofen or advil that's the same medication and i want you to take three tablets every six hours and that's really an anti-inflammatory see if we can eliminate some of that tendinitis type pain that you're getting that inflammation around that achilles tendon i'm gon na also order a couple physical therapy visits and the reason for that is i'd like you to get some strength and stretching understanding i think it's important for you especially here at the beginning is to get some of that real stretching knowledge in and learn how to stretch those muscles before you start these activities and they are gon na help strengthen your your lower extremities also and i want you to come back to me within you know a week to ten days following your first couple physical therapy appointments so i can monitor how you're doing i see no reason for an x-ray at this point but if this continues we're gon na you know if you're still having pain ten days in significant pain without change modification of your activity then we may have to look at more aggressive treatment plans how does that sound for you
[patient] sounds good
[doctor] okay hey did you happen to catch that pittsburgh pang one hockey game last night
[patient] no i i was watching the track meet
[doctor] my gosh the the pang ones are on fire you know they beat up on new york seven to two i mean the hockey's just an amazing sport i i just do you guy do you do a lot of hockey down there in town here
[patient] used to when i lived in detroit
[doctor] oh
[patient] hockey town but not so much anymore
[doctor] no yeah detroit is a hockey town yeah the red wings okay well i'm gon na go ahead and i'll send my nurse in and go ahead and get you discharged and like i said i'd like to see you back here in seven to ten days after that first physical therapy appointment i've got a great phenomenal office staff you just call in once that gets scheduled they will get you in to that next available appointment so take care and i will talk to you later
[patient] thanks | HISTORY OF PRESENT ILLNESS
Dennis Martin is a pleasant 46-year-old male who presents to the clinic today for the evaluation of right heel pain. The onset of his pain began 10 days ago while training for a triathlon. He locates his pain to the posterior aspect of his heel, which radiates proximally into his calf. His pain is aggravated by working out and when he first gets up in the morning. If he sits for a long period, his pain will return upon standing. The patient states that he runs 10 kilometers in the morning. At lunchtime, he tries to get on a bike for about 45 minutes to an hour. In the evening, he goes to the aquatic center and swims for 30 minutes to 1 hour. The patient states that he runs 5 days per week. He adds that he alternates between a long run and a long bike ride on weekends. He currently takes one day off from his exercises. The patient states that he does not stretch at all. He denies any left leg pain.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right heel pain. Denies left leg pain.
PHYSICAL EXAM
MSK: Examination of the right heel: Pain with resisted extension. Mild pain with flexion. Positive calcaneal squeeze test. Severe tenderness to the Achilles tendon. Thompson test is negative, bilaterally.
RESULTS
No new imaging was obtained today
ASSESSMENT
Right Achilles tendinitis.
PLAN
After reviewing the patient's examination today, I had a lengthy discussion with the patient regarding his current symptoms. I have explained to him that his symptoms are likely secondary to overuse. I have recommended that we treat the patient conservatively. The patient was instructed to take at least 1 week off from his training to recover from this. I will provide him with a referral for formal physical therapy to strengthen his right lower extremities. I have advised him to take 3 tablets of ibuprofen every 6 hours for pain. If his pain does not improve with physical therapy, I will recommend obtaining an x-ray.
INSTRUCTIONS
The patient will follow up with me in 7 to 10 days to check on his progress. |
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