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D2N155 | aci | [doctor] so hey christina good to see you today i see you're here you have a nonhealing foot ulcer well also looks like in my notes that you got some you've got type two diabetes and that probably the reason for your ear but ulcer not healing so how you doing today what's going on
[patient] doing pretty good except i ca n't get this ulcer to heal
[doctor] okay how long has that wound been present
[patient] maybe about a year
[doctor] a year well that that's a that's a a long time so when it started i guess did you have any trauma to the foot or did was it just all of a sudden
[patient] no trauma it just it seemed like a little blister and then i picked at it and it did get a little bit red and infected so i talked to my primary about it
[doctor] okay
[patient] i went on some antibiotics it seemed to get better but nothing is really making it go away
[doctor] okay when was the last time you were on antibiotics
[patient] it's probably been five months
[doctor] five months alright do you remember which antibiotics you were on
[patient] keflex
[doctor] keflex alright so kinda does your foot hurt or is it just just the
[patient] no pain but i do n't have much feeling in my foot
[doctor] alright so you've got neuropathy yeah that that that makes sense with the the diabetes so have you had any other symptoms like a fever chills any drainage coming from it
[patient] lately there has been a lot more drainage and i just feel a little more tired
[doctor] okay alright well that that sounds good so today is thursday so what do you have for the weekend
[patient] not too much i'll probably be walking around at the zoo on this ulcer all weekend and eating out and not doing anything my doctor wants me to do
[doctor] no yeah i yeah i know you do have that diabetes i know your pcp probably would n't be excited about you you eating out and all that but you know hopefully we can we i can at least get your your foot a little bit better so your diabetes i know we talked a little bit earlier how is that going for you is it controlled you know what's your your blood sugars running
[patient] yeah they are running better than they were but they are still in the two hundreds so my doctor does n't like that my last a1c was about ten
[doctor] okay alright yeah i i you probably definitely need to get back with your pcp about that because the a1c is is pretty high and i know he probably had you on some medication and insulin and metformin and insulin just to try to to get that lower but
[patient] yes
[doctor] you know we are here for your foot so let's let me take a look at that so we will do a quick exam of your foot so you do n't have any fever your vitals look good so on your your right foot exam i can see here you do have a one by two centimeter two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint i do see some yellow slough that's present with minimal granulation tissue you have no surrounding erythema or cellulitis and there is n't any evidence of fluid collection i do n't see necrosis so there is no dead tissue around it there's no odor and i i do n't appreciate any bony exposure and does it hurt when i touch it here
[patient] no
[doctor] okay so we did a x-ray of your right foot before you came in and it showed no evidence of osteomyelitis that means that there is no bone infection which is really good so let me just talk a little about my assessment and plan of your your foot so you do have that diabetic foot ulcer so what i'm gon na do is i'm going to order a abi or ankle brachial index and that's just to determine your blood supply just to see if we can actually heal that wound i know it's been there for about a year which is a pretty long time and so we just need to see if we can if you do have that blood flow just in case we need to to make other goals for that foot just to depend upon that i'm also gon na do a debridement here have you had that done before of the
[patient] yes i think so
[doctor] okay so you know you know pretty much about that so i'm just gon na try to take off some of that dead tissue we'll do that here in the office afterwards and then i'm going to prescribe you some colaganase ointment and you could just add that to your wound once a day and cover it with a sterile dressing and we're gon na try to continue that until we see it start to shrink and hopefully you know that will work between the debridement and then the ointment did they give you at your pcp they give you a surgical shoe or have you been wearing your regular shoes
[patient] i've just been wearing my regular shoes
[doctor] okay so we're gon na get you a surgical shoe and i want you to to wear that and that can help you take pressure off the area because i know you said you're gon na walk around with this zoo this this weekend so i definitely do n't want you to put much pressure on it from now on and hopefully that can help it heal and so after all that i'm just gon na see you back in two weeks and we could take another look and possible do another debridement of the ulcer so do you have any questions for me
[patient] i do n't think so
[doctor] alright so i'll see you back in two weeks and i hope you have fun at the zoo this weekend
[patient] thank you
[doctor] alright thanks | CHIEF COMPLAINT
Non-healing right foot ulcer.
HISTORY OF PRESENT ILLNESS
Christina Cooper is a pleasant 77-year-old female who presents to the clinic today for the evaluation of a non-healing right foot ulcer. The onset of her wound began 1 year ago with no specific injury. The patient states that it seemed like a blister and she picked at it where it then turned red. The patient was seen by her primary care physician and was prescribed Keflex. She states that the antibiotics improved her symptoms, however they did not resolve them. The patient adds that she was last on Keflex 5 months ago. She denies any pain, however she reports decreased sensation in her foot. The patient also reports increased drainage and fatigue. She states that she has been wearing her regular shoes.
The patient has type 2 diabetes with neuropathy. She states that her blood sugars are running better than they were; however, they are still in the 200's. Her last hemoglobin A1C was 10.
REVIEW OF SYSTEMS
Constitutional: Reports fatigue.
Skin: Reports right foot ulcer and drainage.
VITALS
No fever noted. Vitals look good today.
PHYSICAL EXAM
MSK: Examination of the right foot: There is a 1.0 cm x 2.0 cm wound on the dorsal aspect of the lateral right foot, just proximal to the 5th MTP joint. I do see some yellow slough that is present with minimal granulation tissue. No surrounding erythema or cellulitis. There is no evidence of fluid collection. I do not see necrosis. No odor. I do not appreciate any bony exposure. No pain to palpation.
RESULTS
X-ray of the right foot today reveals no evidence of osteomyelitis.
ASSESSMENT
Right diabetic foot ulcer.
PLAN
I have recommended that we obtain an ankle brachial index to determine her blood supply to see if we can heal the wound. We discussed doing a debridement in office today, which she agreed to. I have also recommended that the patient be placed in a surgical shoe to provide increased support. I have also prescribed the patient collagenase ointment to apply to her wound 1 time per day and cover it with a sterile dressing. I advised the patient that this should be continued until we see the ulcer decrease in size.
INSTRUCTIONS
The patient will follow up with me in 2 weeks to check on her progress. |
D2N156 | aci | [doctor] alright julia so you've been coming to see me for a while now ever since you had an rca stent placed back in twenty eighteen but i see you're here for follow-up after an interior stemi where we had to put in another stent right so like how are you doing
[patient] well i mean it was a real shock for me i thought everything was fine after my last heart attack and then i just started having this horrible chest pain and it would n't go away so i went to the emergency room and yeah they told me i needed another stent
[doctor] wow so you were experiencing similar symptoms similar to what you had the first time
[patient] yeah yeah it was yeah it was bad it was just like the last time
[doctor] okay have you had any chest pain or shortness of breath
[patient] no i think i saw you about six months ago and and i was doing fine
[doctor] okay have you been able to like exercise at all since since you last saw me
[patient] yeah you know i walk my dog everyday and you know we go like a mile and a half or two miles
[doctor] awesome okay yeah you know because like fall is setting in like are you excited
[patient] yeah yeah i'm excited
[doctor] do you have any like plans for the holiday
[patient] no mm-hmm no i'm just you know looking forward to seeing family and having some nice weather and yeah
[doctor] okay so i do wan na ask i know that you have a history of coronary artery disease hypertension and diabetes so i wan na get an idea of like where you stand with those have you been experiencing any kind of leg swelling
[patient] i have noticed that my legs are a little swollen since they sent me home from the hospital
[doctor] okay are you able to lie flat at night when you sleep
[patient] yeah i mean i always use a couple of pillows you know i maybe i've had to sit up a little bit more but i mean for the most part i think it's pretty normal
[doctor] okay and then have you been able to afford your medications and are you taking them like your like you were prescribed
[patient] yeah i'm able to afford afford them i have good insurance i am taking them they told me it's really important to take them so so yeah
[doctor] yeah that's very accurate you know like there are huge consequences to not taking them so if you are noticing any problems please please please please let us know how about your diet are you watching your salt intake
[patient] i mean i'm not i i i have n't really adjusted i mean i tried to watch it after the last heart attack and now you know i i've kind of been less strict with my diet but i'll have to go back to watching the salt intake
[doctor] mm-hmm
[patient] i love pizza it's my favorite food
[doctor] yeah
[patient] my tries are probably my second favorite food
[doctor] what are you for her toppings on pizza
[patient] pepperoni occasionally vegetables
[doctor] mm-hmm alright but you know that pepperoni is pretty high in salt on top of a cheesy pizza right
[patient] i know i know i'm gon na work on it
[doctor] okay so we are we are gon na have to negotiate some of these diet things and then especially since you have diabetes like have you been managing that well
[patient] my i've been watching my sugars yep because i do n't wan na go on insulin so i'm taking that metformin that's why i've been walking my dog i'm trying to stay active
[doctor] okay okay so you know maybe this is just a situation of like where we are on the right path but probably need to step up a few things okay
[patient] okay
[doctor] alright so i do want to do a quick physical exam so you are aware i'm going to be calling out my findings as i run through it alright
[patient] okay
[doctor] alright so your vital signs look good you know so i'm glad that it looks like you're tolerating your medication pretty well on your neck exam i do n't appreciate any jugular venous distention so and then on top of that i'm not i do n't appreciate any carotid bruits so i'm not feeling anything like too concerning on your heart exam though there is a three over six systolic ejection murmur heard at the that i'm hearing at the left base that's not like a huge deal especially considering like what you've been through already in terms of the hospital but it is something that i wan na know in your chart when i listen to you your lungs your lungs are clear over here with your extremities i do notice you know some lower lower edema swelling sorry some lower swelling edema lower limb edema and it it is pitting one plus on your right radial artery the cath site is clean dry and intact without hematoma and i also your right radial artery pulses are palpable so i did review the results of your ekg and they show a normal sinus rhythm and a good r wave progression and a a evolutionary changes that are anticipated after a stemi one of the reasons though that we had you come in is that we noticed on your echo there is a reduced ejection fraction of thirty five percent we are a little bit concerned about that so let's talk about my assessment and plan for you your primary and like first diagnosis is gon na be coronary artery disease right you already have a history of that but you know we're gon na do some things to make we're gon na continue to evaluate that over time i want you to continue your aspirin eighty one milligrams daily and your brilinta ninety milligrams twice daily i wan na continue you on a high dose statin called lipitor and you're gon na be taking that eighty milligrams a day and we're gon na continue you on your toprol and that's gon na be fifty milligrams daily i am gon na refer you to cardiac rehab so we can get you some education and give you some confidence to get back to exercising regularly i know it was kinda scary to have such an episode but i promise like most of the patients i have love cardiac rehab and i think you'll do pretty well for your second diagnosis we have newly you have newly reduced left ventricular dysfunction and moderate mitral regurgitation what i think is like what that means is that you're you're pumping like the way that your heart is pumping is a bit concerning but i think like given your history that it will improve over time they got you into the cath lab pretty quickly so i think that the muscle is just kinda like stunned like surprised and since you're compliant with your meds i think you will recover we are gon na continue you on your lisinopril twenty milligrams daily however considering that you are retaining fluid i think that your third diagnosis is like we are crossing into acute heart failure i'm gon na prescribe something called a diuretic it's called lasix and i do want to we need to take that forty milligrams once a day i wan na add aldactone twelve . five milligrams daily and i need you to get labs finally we will repeat another echo in about two months last but not least there is the hypertension your blood pressure seems fine i think with the aldactone that you'll tolerate that pretty well but we do want to maybe get you into some nutrition counseling to consider like what other diet options might be available to you maybe suggestions of things that you have n't thought about like cutting out meat especially any kind of preserved meat like pepperoni but maybe finding you some alternatives how does that sound
[patient] that sounds good yeah so i'm yeah as long as you tell me i'm gon na get better i believe you
[doctor] yes yeah i i strongly believe this is our best course of action and that you will get better given enough time i i see that you are making efforts i'm really glad that you are out there walking and that you're cognizant of your diet and willing to make changes we will just you know monitor it over time okay
[patient] okay
[doctor] alright thank you | CHIEF COMPLAINT
Follow up status post inferior STEMI.
SURGICAL HISTORY
RCA stent 2018
MEDICATIONS
aspirin 81 mg daily
Brilinta 90 mg twice daily
Lipitor 80 mg daily
Toprol 50 mg daily
lisinopril 20 mg daily
metformin
REVIEW OF SYSTEMS
Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Musculoskeletal: Reports bilateral leg swelling.
VITALS
Within normal limits
PHYSICAL EXAM
Neck
- General Examination: No jugular venous distention.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: No carotid bruits. A 3/6 systolic ejection murmur is heard at the left base.
- Examination: Right radial artery cath site is clean, dry, and intact without hematoma. Radial artery pulses are palpable.
Musculoskeletal
- Examination: Bilateral lower limb edema. Pitting 1+.
RESULTS
EKG is reviewed and demonstrates a normal sinus rhythm. Good R wave progression. Evolutionary changes that are anticipated after a STEMI.
Echocardiogram is reviewed and demonstrates a reduced ejection fraction of 35%.
ASSESSMENT AND PLAN
1. Coronary artery disease.
- Medical Reasoning: The patient has a history of coronary artery disease that we will continue to monitor.
- Medical Treatment: She will continue aspirin 81 mg daily and Brilinta 90 mg twice daily. She will continue Lipitor 80 mg a day and Toprol 50 mg daily. I am going to refer her to cardiac rehab for education and to gain confidence to resume exercising regularly.
2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.
- Medical Reasoning: A recent echocardiogram revealed a reduced ejection fraction of 35%. She was able to be treated in the cath lab in a timely manner, so I think that the muscle is just stunned. Given her history. it will improve over time.
- Patient Education and Counseling: I advised the patient that she will recover since she is compliant with her medications.
- Medical Treatment: Continue lisinopril 20 mg daily.
3. Acute heart failure.
- Medical Reasoning: The patient is retaining fluid.
- Medical Treatment: I am going to prescribe Lasix 40 mg once a day. I want to add Aldactone 12.5 mg daily. I will order lab work. We will obtain a repeat echo in approximately 2 months.
4. Hypertension.
- Medical Reasoning: Blood pressure is well controlled. She will tolerate the Aldactone well.
- Patient Education and Counseling: I encouraged the patient to continue exercising and to be cognizant of her diet. I explained that there are healthier alternatives available to reduce the amount of preserved meats she consumes.
- Medical Treatment: Continue lisinopril 20 mg daily. The patient received a referral to nutrition counseling to consider what other diet options might be available to her.
5. Type 2 diabetes.
- Medical Reasoning: Stable.
- Patient Education and Counseling: I encouraged the patient to continue monitoring her blood glucose levels.
- Medical Treatment: Continue metformin as prescribed.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up as instructed. |
D2N157 | aci | [doctor] hey jose how are you doing it's been about you know three or four months since i last saw you what's going on
[patient] i'm doing okay i i guess the medications are helping i'm concerned about all the medications i'm taking but i think i'm doing okay
[doctor] yeah yeah you are on a fair amount of medications you know we do have you on those medications because you did have a heart attack about six months ago they put that that stent into your left anterior descending artery and so that's a major artery on the left side of your heart and so we need to keep those stents open and and kinda help your heart heal so it is gon na be very important for you to continue on those medications so you're still taking your aspirin and are you still taking the brilinta
[patient] yes and and fish oil
[doctor] and fish oil okay good now how are you doing with the crestor i know that that's you know that's the statin that's the cholesterol medication you were concerned that it might cause you to have some muscle aches are you taking that
[patient] i i think i'm doing good but i i am i feel like i i when i i guess the only complaint that i have is ever since i i do n't know if this is the heart attack or if this this is the the medication but when i stand up real fast i get really dizzy
[doctor] you get you get dizzy okay yeah you know we do have you on a what we call a beta-blocker metoprolol i think your dose is fifty milligrams once a day and you know sometimes it takes a little bit for your body to adjust to that but yes if you stand up too quickly it can cause you to be a little dizzy so
[patient] okay okay that makes sense okay that's good to know because i did n't know what what what the problem was so can i ask you a question regarding the stents
[doctor] yep
[patient] how long do i have to have that in there
[doctor] so the stents are permanent we do n't we do n't remove them so yep so that's why it's gon na be super important for you you know you're gon na be on aspirin for the rest of your life and then i'm gon na keep you on that brilinta for another six months that's gon na help prevent the that stent from clogging
[patient] okay okay do i need to ever replace the stents then
[doctor] no i mean every so often the stents can become narrowed again but you know that's why you're seeing me your cardiologist so that i can follow you for that now if you start to have symptoms again of any chest pain like you had before or any shortness of breath when you start to exert yourself i want you to tell me and we might have to go ahead and send you for further testing to make sure that those stents are okay but typically if you continue to take the medication watch your diet that type of thing your stents will will stay open for a long time
[patient] okay alright that sounds good you know i have n't i had a i had i know you asked me to follow up with the dietitian because i had diabetes as well which probably contributed to my heart attack
[doctor] yeah
[patient] i may need a new order i do n't i i forgot who i was supposed to talk to
[doctor] okay that's okay yeah i certainly can help you with that now managing your diabetes is also going to play an important role in your coronary artery disease which it sounds like you already know that which is really good so i will put in another referral for diabetic education for you how are you doing watching your sweets i know that you know you do have an afinity for those chocolate chip cookies
[patient] it's okay my a1c was n't where i wanted but my glucose is coming in in about one thirty
[doctor] okay
[patient] fasting
[doctor] okay what was the what was the a1c the hemoglobin a1c if you do n't mind me asking
[patient] i thought it was close to sixty
[doctor] okay yeah that's really high so we want it to be about six so you you do have some work to do with your diet
[patient] yeah yeah so okay so i know you asked me to do a blood test so i did that i was wondering if you got the results
[doctor] i did you know i looked at the results of your kidney function that's what we call your creatinine just because you had some contrast dye and sometimes contrast dye can impact the kidneys and your kidney function is stable which is great when was the last time you saw your nephrologist
[patient] oh
[doctor] that's your kidney doctor
[patient] i'm a bad i'm a bad patient so probably a year ago
[doctor] okay you know you do have the stage three ckd so that's the the stage three kidney disease so it is gon na be important for you to follow up with your nephrologist just to make sure that everything is okay now i did check your kidney function and and it was fine but are you staying away from things like motrin and advil
[patient] right yeah that's i threw all of those out
[doctor] okay good okay perfect now i know that you're from the west coast are you super excited that la one the super bowl or are you more of a san francisco forty nine or span
[patient] i'm a more of a san francisco fan
[doctor] so do you like jimmy g do you think he can beat erin rogers again
[patient] okay we'll see we'll see what happens but i'm pretty flexible when he comes to you know that is but one thing that since i ca n't take motrin what pain killer can i take for headaches
[doctor] you can take tylenol
[patient] okay
[doctor] yeah
[patient] alright that sounds good
[doctor] yeah
[patient] okay
[doctor] okay
[patient] this is i i do n't think i have any other question the only thing i'm gon na need is a i need some refills on my medications
[doctor] yeah i can do that but i do wan na just do a physical exam on you okay so and looking here at your vital signs here you know your your vital signs look quite good you know your blood pressure is what right where it should be it's about one twenty seven over eighty which is great so you're doing a good job taking your metoprolol now in terms of on your neck exam i do n't appreciate any jugular venous distention or carotid bruits on your heart exam i do appreciate a slight three out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do appreciate some one plus nonpitting edema now what does that mean what does that mean jose so all of that means is that i do hear a little heart murmur on your heart which i've heard before in the past and it does n't it does n't look like you're retaining any fluid which is good but you do have a little puffiness in your legs which sometimes some of the medications can cause
[patient] yeah i do have that
[doctor] so let's just go over a little bit about my assessment and and plan for you going forward so for your first problem of your coronary artery disease i think you're doing really well i wan na go ahead and refer you for cardiac rehab just so that you can be more active and have some confidence in in exercising again okay and i am gon na go ahead and refill your metoprolol your crestor forty milligrams once a day as well as the aspirin okay i do n't think we need to proceed with a a stress test or anything at this time but you know to let me know if you have any symptoms okay
[patient] okay
[doctor] okay for your
[patient] sounds really good
[doctor] good for your second problem of your stage three chronic kidney disease i am gon na reach out to doctor miller and make an appointment for you to be seen just because again i think it's important for you to follow up with your nephrologist okay
[patient] okay
[doctor] and then for your third problem of your diabetes i am gon na go ahead and order another hemoglobin a1c and i'm gon na put that referral in for the dietitian to give you some dietary education and i'm gon na go ahead and talk with your primary care physician about your your insulin regimen okay
[patient] okay
[doctor] any questions
[patient] yeah you know i've been kinda down ever since i had my heart attack is there any medication that i could take to make me feel a little bit less sad
[doctor] yeah i mean are you having any thoughts of of harming yourself or harming others
[patient] no no i just feel kinda down
[doctor] you feel kinda down what's your
[patient] life sucks
[doctor] what well i do n't think so what what's your support system like
[patient] you know i i live with my dog and that's it so it's kind of you know lonely
[doctor] okay alright well would you be interested in in like a referral to psychiatry or something like that so that you have someone to talk to about some of of issues because medication can help but i do i think it's important to have you know talk some of these things out
[patient] okay yeah you know i'll give that a try i mean i'm retiring i got plenty of time
[doctor] okay so why do n't we go ahead and i'm gon na place a referral to psychiatry for you know you know difficulty adjusting after having a heart attack maybe some some mild depression okay does that sound okay okay
[patient] yeah that sounds really good thank you
[doctor] okay you're welcome anything else
[patient] so you will do the medication refill do i so that's automatic
[doctor] yep i'm gon na put them into the computer and and whatever pharmacy you want yep mm-hmm
[patient] okay alright sounds great thank you
[doctor] okay you're welcome i'll be in touch bye
[patient] okay alright bye-bye | CHIEF COMPLAINT
Follow-up.
MEDICAL HISTORY
Patient reports having a heart attack 6 months ago, coronary artery disease, diabetes.
SURGICAL HISTORY
Patient reports history of stent placement at the left anterior descending artery.
SOCIAL HISTORY
Patient reports that he is from the west coast and is a San Francisco 49ers fan. He lives with his dog.
MEDICATIONS
Patient reports taking aspirin, Brilinta, fish oil, Crestor, metoprolol 50 mg once a day,
REVIEW OF SYSTEMS
Musculoskeletal: Reports non-pitting lower extremity edema. Denies muscle aches.
Neurological: Reports dizziness and headaches.
Psychiatric: Reports depression. Denies suicidal ideation or homicidal ideation.
VITALS
Vital signs look good with blood pressure of 127/80.
PHYSICAL EXAM
Neck
- General Examination: No jugular venous distention or carotid bruits.
Respiratory
- Assessment of Respiratory Effort: Normal respiratory effort.
- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.
Cardiovascular
- Auscultation of Heart: Slight, 3/6 systolic ejection murmur heard at the left base.
Musculoskeletal
- Examination: 1+ non-pitting lower extremity edema.
RESULTS
Lab results are reviewed and show stable a creatinine level.
ASSESSMENT AND PLAN
1. Coronary artery disease.
- Medical Reasoning: The patient is doing very well and has been compliant with all medications. A slight 3/6 ejection murmur was heard on exam, however, this is stable and has been present in the past. He is experiencing 1+ non-pitting edema, but this seems to be medication related.
- Patient Education and Counseling: Patient was advised that his stents will remain in place permanently and that they typically do not require replacement. We discussed it is common to experience dizziness when standing quickly and that this should resolve once he is adjusted to his medications. We also discussed that cardiac rehab will be beneficial in helping him become more active and confident with exercising. He was advised to watch for symptoms such as chest pain or shortness of breath on exertion as this would need further testing such as a stress test.
- Medical Treatment: Referral to cardiac rehab was provided. A refill for metoprolol 50 mg once a day and Crestor 40 mg once a day was also provided. He is also advised to continue aspirin daily long term as well as Brilinta for the next 6 months.
2. Stage 3 chronic kidney disease.
- Medical Reasoning: Patient's most recent creatinine levels are stable.
- Patient Education and Counseling: We discussed the importance of following up with nephrology.
- Medical Treatment: He will follow up with his nephrologist, Dr. Miller.
3. Diabetes.
- Medical Reasoning: Patient reports most recent hemoglobin A1c was 16.
- Patient Education and Counseling: We discussed the importance of diabetes management and how plays an important role in his coronary artery disease. He was advised that his hemoglobin A1c goal will be 6.
- Medical Treatment: Repeat hemoglobin A1c was ordered today. A dietitian referral for diabetes education was also provided. We will contact his primary care physician regarding his insulin regimen.
4. Mild depression:
- Medical Reasoning: Patient reports feeling depressed and having a hard time adjusting since having his heart attack. He mentions he is also lonely and does not have a support system.
- Medical Treatment: Referral to psychiatry was provided today.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
|
D2N158 | aci | [doctor] yeah so sorry so barbara is a 31 -year-old female and she has history of diabetes type two and asthma and she is here today with abdominal pain so barbara tell me a little more about your abdominal pain what's been going on
[patient] so i've been having this pain for the past one week and as you know i have a longstanding history of diabetes and i guess i've been drinking too much coffee lately i do n't know if that triggered my gastritis so
[doctor] yeah
[patient] i think it's been but lately
[doctor] okay alright and so is it increasing in severity would you say or staying about the same or what
[patient] it's gradually increasing for sure
[doctor] okay alright and along with the pain have you had any nausea or vomiting or diarrhea
[patient] nausea and vomiting is on and off
[doctor] hmmm
[patient] so i would say i've experienced nausea for about like three times in the past week
[doctor] okay okay and and so and you vomited how many times
[patient] a couple of times
[doctor] okay alright been drinking a lot of coffee you said too uh is that is that starbucks i love those nitrocolbrus and starbucks we ever had those those are incredible
[patient] yeah
[doctor] that's
[patient] and the venti
[doctor] yeah the for sure you got ta go venti on that you really have to coax them into it though they wo n't even give you it's it's like you need a license to get a venti on that that nitro it's so strong so that's my achilles heel i tell you but okay so you think that might have you think maybe coffee contributed to your abdominal pain uh you you you you've been drinking more coffee and maybe that's related as you're thinking
[patient] yeah i think so because i started last week and towards the end of last week my coffee intake was pretty bad so i've been controlling myself this week and you know i i probably just had one cup
[doctor] okay yeah okay and so is the pain in your upper abdomen or where in your abdomen is it
[patient] it's on both the sides of my upper abdomen
[doctor] hmmm okay
[patient] so i it also increases when i work out like if i wan na jog or like go for a run my abdominal pain just like spikes you know so i have to take it easy
[doctor] okay alright understood you've not had any fever with that pain have you
[patient] no i have n't
[doctor] okay alright and so how about your diabetes how's your diabetes been doing how your blood sugars been what low one hundreds two hundreds where where is it
[patient] i think it's been under control it's eight hundred so
[doctor] okay good and you're still taking the metformin five hundred milligrams once a day right no actually it looks like last visit we increased that to five hundred milligrams twice per day is that correct
[patient] yes that's probably helping me keeping it under control so
[doctor] okay good good and then for your asthma have you had any recent asthma attacks and are you still taking the flovent twice a day and albuterol as needed for wheezing
[patient] yes but sometimes i forget you know i have n't had any asthma attacks lately so i just figured i could decrease
[doctor] yep okay
[patient] i think that's a good decision though
[doctor] yeah well better to stay on the flovent daily and then just use the albuterol if you need it but if you stay on the flovent daily it will decrease the frequency of those attacks so yeah alright well let's go ahead and examine you okay so on your physical exam it's pretty normal for the most part unremarkable but i i'll i'll say on your on your heart exam you do still have a grade three out of six systolic ejection murmur that's unchanged from your prior exam and and i'm not worried about that we're kinda watching that but it just means i hear some heart sounds when your valves are moving and otherwise normal heart exam for your abdominal exam you do have mild tenderness in the epigastrium of your abdomen your abdomen's otherwise soft there's no tenderness in the right lower quadrant whatsoever and there is no significant tenderness in the right upper quadrant so i think you know that's right where your stomach is in the upper abdomen so i think that you know that may be you may be right this could be some gastritis so so then otherwise on your exam on your lung exam you do have some mild end expiratory wheezes very faint and otherwise normal lung exam with excellent air movement and otherwise pretty normal physical exam so let's talk about your my assessment and your plan here so first of all for the first problem of the abdominal pain i do think that you have acute gastritis and i think this is probably related to the caffeine intake and i i know that you've had a a moderately heavy history of alcohol use too so i want you to cut back on the alcohol as well you know keep that down to a dull roller like maybe keep that less than two or three drinks a week would be great and then also cut back on the caffeine and that should help and i'm going to write you a prescription for zantac as well as we need and so i'll write you a prescription you can take that twice a day that should help with the acid in your stomach and the pain and then i'm going to check a urinalysis a urine pregnancy test a cbc a comprehensive metabolic panel as well and we'll see what those results show just to be sure it's nothing else going on and then for your second problem of diabetes type two let's continue you on the metformin but i wan na adjust the dose slightly i'm gon na increase the morning dose to one thousand milligrams and the evening dose we can keep at five hundred so we'll go metformin one thousand milligrams in the morning and five hundred milligrams in the evening please continue to check your blood sugars let me know what they are when you come back you know we just keep track of those and then we'll see you back in four weeks by the way i wan na have you follow up with me in four weeks and for your third problem of asthma let's continue you on the flovent that seems to be doing pretty well continue to take that daily and then also albuterol as needed so how does that sound for a plan any other questions comments suggestions
[patient] that sounds good and i also feel like i'm eating been eating a lot of spicy food
[doctor] hmmm
[patient] lately that could be contributing towards my gastritis so i'm gon na cut back on that as well
[doctor] okay yeah i'd also recommend while this is hurting you definitely cut back on the spices the spicy food easier said than done sometimes i know but yep yep alright sounds good well listen i'll see you back in four weeks give me a holler if if you have any questions or anything else in the meantime
[patient] i will
[doctor] alright you take care sure you got | CHIEF COMPLAINT
Abdominal pain.
MEDICAL HISTORY
Patient reports history of diabetes type 2, asthma, and gastritis.
SOCIAL HISTORY
Patient reports history of moderately heavy alcohol use. She also enjoys coffee.
MEDICATIONS
Patient reports taking metformin 500 mg twice daily, Flovent twice daily, and albuterol as-needed.
REVIEW OF SYSTEMS
Constitutional: Denies fever.
Gastrointestinal: Reports abdominal pain, nausea, and vomiting. Denies diarrhea.
PHYSICAL EXAM
Respiratory
- Auscultation of Lungs: Mild end expiratory wheezes, very faint.
Cardiovascular
- Auscultation of Heart: Grade 3/6 systolic ejection murmur, unchanged from prior exam.
Gastrointestinal
- Examination of Abdomen: Mild tenderness in the epigastrium. Abdomen is soft. No tenderness in the right lower quadrant. No significant tenderness in the right upper quadrant.
ASSESSMENT AND PLAN
1. Abdominal pain.
- Medical Reasoning: This appears to be acute gastritis, likely related to her increased caffeine intake. She has a history of moderately heavy alcohol use as well.
- Patient Education and Counseling: We discussed appropriate limitations for alcohol intake as well as spicy foods.
- Medical Treatment: Reduce caffeine intake. Reduce alcohol intake. Prescription for Zantac twice daily provided. I'm going to order a urinalysis, urine pregnancy test, CBC, and a comprehensive metabolic panel.
2. Diabetes type 2.
- Medical Reasoning: She is doing well, but I want to make a slight adjustment to her dosage.
- Patient Education and Counseling: I advised her to continue with home monitoring and bring those readings to her next appointment.
- Medical Treatment: Metformin 1000 mg in the morning and 500 mg at night.
Continue home blood sugar monitoring.
3. Asthma.
- Medical Reasoning: She seems to be doing well on her current regimen and has not had any asthma attacks lately.
- Patient Education and Counseling: She was advised to take Flovent daily despite no recent asthma attacks as this will decrease the frequency of her attacks.
- Medical Treatment: Continue on daily Flovent. Continue albuterol as-needed.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up in 4 weeks. |
D2N159 | aci | [doctor] good afternoon alexis i understand you're having some issues with your hand
[patient] yes i sit at the keyboard all day long and recently i've been having some numbness and tingling in my right hand
[doctor] okay how long has that been going on
[patient] i do n't know probably on and off for six months but over the last month or so it's been a little more persistent
[doctor] okay okay and when does that numbness and tingling do you get a lot of pain with it first let me ask that question
[patient] some pain
[doctor] some pain
[patient] mostly when i'm actually typing on the keyboard is when i experience the pain
[doctor] okay
[patient] but the numbness and tingling is all the time now
[doctor] okay and when you get this pain what makes it better is it stopping and just resting for a while or do you take medications or try other
[patient] i've been taking ibuprofen so ibuprofen and seem like not typing on the keyboard helps the most
[doctor] okay
[patient] the other thing that makes it hurt is my mouse
[doctor] your mouth okay
[patient] wow
[doctor] yeah when you're moving that around okay
[patient] yeah
[doctor] does this pain ever wake you up in the middle of the night or the pain or the tingling
[patient] no
[doctor] no okay
[patient] not affecting my sleep hmmm
[doctor] okay so and you're using motrin for for ibuprofen for for the pain well let me go ahead and take a take a look here at your is it both hands or just your right hand
[patient] mostly my right hand
[doctor] mostly your right hand okay so let's go ahead and take a look at that right hand when i bend your wrist does that cause any pain
[patient] yes
[doctor] it does okay and so you do have some pain on extension and if you pull your your hand wrist up towards you does that cause the pain also
[patient] yes
[doctor] yeah okay so you do have pain on flexion and extension and when i touch the fingertips here now you said you had some numbness in your thumb and your index finger and a little bit in your your middle finger the other two fingers they feel okay or do you think that there is different than the other hand
[patient] yeah for some reason it really is just that the thumb the pointer in the middle finger that i experience the most symptoms with
[doctor] okay
[patient] not why that is
[doctor] okay so i i want you to grip my hands here and just squeeze tight okay so you do have a a little bit of a less grip strength on the right and that's typical that we would see with this type of pain and and numbness that you have going on now i want you to turn your arm over for me and i'm gon na touch on or tap on the inside of your wrist or or forearm and when i do that i can see your face you're grimacing so that that that must cause that shooting pain yeah okay so you do have a positive tinel's sign so in alexis what i think is going on is that you have a a carpal tunnel syndrome and we see that frequent
[patient] i was afraid of
[doctor] yeah you see this frequently but people who are doing data entry spend a lot of time on keyboards or you know some a lotta manufacturing people who do a repetitive procedure again and again will get that type of pain so here is my plan i'd like to put you in a splint and it's it's it's kind of a wrist splint i would like you to wear that at night that will help with that i want you to continue with the ibuprofens but i would like you to go up to six hundred milligrams four times a day and
[patient] okay
[doctor] we're gon na do that now i am going to order some a a outpatient test called an emg where we look at that nerve conduction study in that wrist and that's really what's happening here is you've got some thickening in the the in the wrist and the the the membranes of the wrist that are just pressing down and just compressing some of those nerves any other questions for me for now if that test comes back positive and we'll talk about that later on your next visit if it comes back positive we may have to do we're gon na stick with conservative treatment first but we may consider some surgery where i can go in and release that impingement on your nerves through your wrist it's a simple outpatient procedure and then i think you would feel better how does that sound
[patient] that sounds like a good plan i was hoping maybe i could get some relief with some therapy rather than having to go to surgery so i like that plan very much
[doctor] yeah we'll start with the the wrist splint and once i get the nerve conduction studies that will give me another idea whether or not i need to send you some physical therapy in addition or if we need to go directly to surgery but that will all hinge on that nerve conduction test do you so do you have any further questions
[patient] no that's great thank you so much
[doctor] thank you very much | CHIEF COMPLAINT
Right hand pain.
HISTORY OF PRESENT ILLNESS
Alexis Gutierrez is a pleasant 33-year-old female who presents to the clinic today for the evaluation of right hand pain.
Approximately 6 months ago, the patient began experiencing intermittent episodes of numbness and tingling in the 1st, 2nd, and 3rd digits on her right hand. The numbness and tingling has become constant over the past month or so and is accompanied by pain with typing and using a mouse, which she does all day while working on a keyboard. She denies any sleep disturbance associated with her symptoms. Rest and ibuprofen have been the most helpful at providing symptomatic relief.
SOCIAL HISTORY
The patient reports that she works on a keyboard all day.
MEDICATIONS
The patient reports that she has been taking ibuprofen.
REVIEW OF SYSTEMS
Constitutional: Denies sleep disturbance.
Musculoskeletal: Reports pain in the 1st, 2nd, and 3rd digits on the right hand.
Neurological: Reports numbness and tingling in the 1st, 2nd, and 3rd digits on the right hand.
PHYSICAL EXAM
MSK: Examination of the right hand: Pain with flexion and extension of the wrist.. Decreased grip strength on the right compared to the left. Positive Tinel's sign.
ASSESSMENT
Right carpal tunnel syndrome.
PLAN
After reviewing her symptoms and exam findings, I believe her symptoms are secondary to carpal tunnel syndrome. We discussed the nature of this condition, as well as her treatment options, in detail. I recommend we treat this conservatively with nighttime wrist splinting and ibuprofen, but I want to increase her dose to 600 mg 4 times daily. I'm also going to order an EMG/Nerve conduction study for further evaluation. If this is positive, we can consider additional treatment with physical therapy or surgical intervention with carpal tunnel release. |
D2N160 | aci | [doctor] hey good to see you philip so i see here you're coming in you had some right elbow pain also you have a past medical history of hypertension diabetes we are gon na check up on those as well so can you tell me what happened to your elbow
[patient] sure i hurt it about a week ago playing lacrosse with my kids just suddenly started hurting me when i was throwing the ball
[doctor] okay okay so how old are your kids
[patient] my oldest is thirteen and the other one is ten i was playing with a thirteen -year-old
[doctor] okay yeah i know i i play with my kids sometimes and i think i'm getting too old to do all that so i just i've hurt myself before as well alright so with your your elbow what part of your elbow would you say hurts
[patient] it's really like right at the point of the elbow right at right at like the tip of it
[doctor] okay
[patient] and it just it hurt hurts anytime i move it
[doctor] anytime i move it do you remember falling
[patient] no i do n't think so but my kid got pretty rough with me and was checking me several times with a sick
[doctor] okay
[patient] so i could have got hit there
[doctor] okay alright yeah that that that definitely makes sense so how would you describe the pain is it like a dull pain is it stabbing what what would you say
[patient] it it's a pretty sharp pain
[doctor] okay
[patient] anytime i move
[doctor] okay and does it radiate down your arm or does it stay in that one spot
[patient] it radiates down the forearm
[doctor] radiates down the forearm alright so have you taken any medications for it to make it better
[patient] i tried taking advil couple of days but i usually just forget about it
[doctor] okay when you took it did it did it help at all did it change your your pain score
[patient] yeah i i think it helped some
[doctor] okay that's good alright so we'll we'll do a physical exam on that elbow we'll take a look at it in a second but i do wan na talk to you about your your hypertension you came in today i know you have past medical history of hypertension came in today your blood pressure's a little bit high it was a one fifty over seven over ninety which is pretty high today i see you're on twenty of lisinopril have you been taking that daily
[patient] yes
[doctor] okay so maybe you just have a little little white coat syndrome i know i have that myself and even though i'm a physician i i still do n't like to go to the doctor so i definitely understand how about your diet i know we talked a little bit about that before and you said kinda during the pandemic you fell off a little bit how you been doing that have you been lowering your salt intake
[patient] yeah but i only eat low salt items avoid adding salt to food kind of the whole whole family follows like a you know like a mediterranean diet
[doctor] okay
[patient] we try to be pretty good about it
[doctor] okay yeah that's good that that's that's definitely good yeah i know a lot of people during the pandemic it was you know sitting at home and and eating more than we should but that's i'm very happy that you've been compliant and you have that low salt diet so let's talk about your diabetes i think you see here on on five hundred of metformin are you taking that as well daily
[patient] yes
[doctor] okay and your blood sugars how have they been
[patient] since i do n't take insulin i do n't check it everyday when i have checked it it's usually running somewhere between eighty to a hundred
[doctor] okay yeah that's that's really good yeah so i that's that's pretty good so what we're gon na do we're gon na get a a1c just to see you know that range and it's possibility we can we can you know lower that metformin dosage but we will do that after your visit then we will take a look at that so lem me go ahead and will do that quick exam of your elbow but first i want to make sure you're not having any chest pain or anything like that
[patient] no
[doctor] no belly pain
[patient] no
[doctor] alright so listen to your lungs so your lungs are clear bilaterally listen to your heart so your heart exam you do still have that grade two out of six systolic ejection murmur but we know it about that before so let me take a look at your elbow so when i press right here on the back of your elbow is that painful
[patient] yes
[doctor] alright so when i have you you you flex and extend it it's painful does that does that hurt
[patient] yes it does
[doctor] alright so your right elbow exam shows you have pain to palpation of the olecranon area of the posterior elbow you do have mild pain with flexion and extension but you do have also normal range of motion at that elbow so we we did do an x-ray before you came in and luckily nothing's broken no fracture no bony abnormality so it's a normal x-ray which is really good so let me just talk to you a little bit about my assessment and plan for you so you have a elbow contusion i believe your son did hit you with the lacrosse stick and it caused that that pain i see some swelling little inflammation there as well you have a little bit of a bruise i think that's that's what happened so for that i know you're having some pain i'm gon na prescribe you eight hundred milligrams of ibuprofen you can take that twice a day and that should help with some of that swelling and pain i also want you to ice it three times a day for twenty minutes at a time that should also help with the swelling and pain and just for the time being for the next couple of weeks just you know maybe you know not play lacrosse with your son just to help that heal then you can get back on on the field so for your your high blood pressure we're just gon na keep you on the hypertension we'll just keep you on that twenty milligrams of lisinopril looks like you're doing great with that and your diet and then for your diabetes we will keep you on the five hundred milligrams of metformin and we will also get a a1c just to check your levels and see if we do need to adjust the medication in the future alright so do you have any questions for me
[patient] no sounds good
[doctor] alright so we will see you next time and my nurse will be in with those prescriptions
[patient] alright thank you | CHIEF COMPLAINT
Right elbow pain.
REVIEW OF SYSTEMS
Cardiovascular: Denies chest pain.
Gastrointestinal: Denies abdominal pain.
Musculoskeletal: Reports right elbow pain.
VITALS
Blood pressure: 150/90 mmHg
PHYSICAL EXAM
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
Grade 2/6 systolic ejection murmur.
Musculoskeletal
- Examination: Pain to palpation of the olecranon area of the posterior elbow. Mild pain with flexion and extension but otherwise normal range of motion. There is swelling about the elbow, as well as mild ecchymosis.
Hematology/Lymphatic/Immunology
- Examination: Bruising noted over the right elbow.
RESULTS
X-ray of the right elbow was reviewed and demonstrates no evidence of fracture or bony abnormalities.
ASSESSMENT AND PLAN
1. Right elbow contusion.
- Medical Reasoning: The patient sustained an injury to his elbow when his son struck him with a lacrosse stick. His x-ray and exam findings are consistent with an elbow contusion.
- Patient Education and Counseling: I encouraged the patient to avoid playing lacrosse for the next couple of weeks, just until his elbow heals. After that, he should be fine to continue playing normally.
- Medical Treatment: I'm going to prescribe him ibuprofen 800 mg twice daily to help with some of the pain and swelling. He should also ice the area in 20-minute intervals 3 times per day to further reduce his symptoms.
2. Hypertension.
- Medical Reasoning: This appears to be well-controlled with dietary modifications and lisinopril.
- Patient Education and Counseling: I encouraged him to keep up with his dietary modifications.
- Medical Treatment: We will keep him on lisinopril 20 mg daily.
3. Diabetes.
- Medical Reasoning: This appears to be well controlled at this time.
- Medical Treatment: We will keep him on metformin 500 mg and order a hemoglobin A1c to evaluate any need for medication adjustments.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. |
D2N161 | aci | [doctor] patient is an 82 -year-old male with past medical history significant for hypertension and stage three chronic kidney disease who presents for hospital follow-up after an acute on chronic chf exacerbation alright hey hey kevin how are you doing today
[patient] hi document well i mean i thought i was doing good but then i've been trying to watch my diet like you said and i really noticed that my ankles were swelling and then one day i got really super short of breath and i even had to call nine one one now when the paramedics got there they put me on the special mask to breathe when i got to the er the doctor in the er said my blood pressure was super high
[doctor] yeah okay so yeah so i saw that and i was notified that you were in the hospital for heart failure now i do see here that your blood pressure was two hundred over ninety are you have you been taking your medications
[patient] well i take them most times but i do n't know sometimes i miss a dose or two but i really do try to take it for the most part
[doctor] okay well good i'm i'm glad you're trying there you do need to take them though okay consistently now you said you were watching your diet did you have some slips you said your ankles were swelling
[patient] well be honest with you you know i'm a big cheese man i love me some football and and we go to parties on the weekends and i mean i i ca n't help it i really like pizza and i love chicken wings and i know i should n't have them but they are good and i want to eat them when i'm with my friends
[doctor] man i know i i totally understand i mean i do love pizza too and i love chicken minks but i do love them with dallas cowboys not so much the cheese but everybody's got your preference but but you do have to you know you have to watch those right you can you can you can have a little pizza maybe a little chicken wings every now and then but you know when you go to a lot of parties on weekends we we have to really watch that okay
[patient] yeah i mean you're wrong about the cowboys but yeah i guess you're right about everything else
[doctor] okay thank you so tell me how are you feeling now though
[patient] man doc i feel good i was in the hospital a couple of days and they gave me this medicine made me go to the bathroom like nobody's business and then they gave me this water pill through my iv and i think i'm on different medications for my blood pressure now too but and i feel so much better now
[doctor] okay well that's good to hear so have you been watching your diet too and taking taking your pills since you've been home
[patient] yeah i've been doing just what they told me to do because i do n't wan na go back to the hospital
[doctor] okay alright and we do n't want you to go back to the hospital it's never a good experience so you know being in a hospital it's better to be well and be at home and watching your chiefs play now have you bought a blood pressure cuff at home i know we talked about that
[patient] yes ma'am i finally did what you told me to do and i ordered one and it came last week i've been checking it about every other day and my blood pressure has been really good
[doctor] good very good how about have you been having any shortness of breath or problems sleeping since you've been home
[patient] nope no shortness of breath i can get up and move around i do n't have any trouble and no problem sleeping i do have a good afternoon nap
[doctor] good that's good you need to rest every now and then as well and now tell me have you had any chest pain
[patient] no chest pain at all since i've been home
[doctor] okay alright very good alright well i'm gon na go ahead and do a quick physical exam on you here kevin and so i'm looking at your vital signs here and your blood pressure today is actually pretty good at one twenty eight over seventy two your vital signs also look good in general your heart rate's been nice at like seventy nine so that's very nice and normal your respiratory rate is twenty six that's probably because you're talking to me here but that's that's alright and then your o2 sat is ninety nine percent so that's good and now on your neck exam there is no jugular venous distention so that's good on your heart exam i appreciate a two out of six systolic ejection murmur which i have heard this before and it's stable so we will just keep on monitoring that okay now your lungs here lem me listen okay they're clear bilaterally and let me take a look at your legs real quick here kevin okay so your lower extremities they do show a trace of edema so that that's gon na be that we're gon na be able to help that with the water pills that you're taking okay
[patient] okay
[doctor] now i did review the results of your echocardiogram which shows a preserved ef of fifty five percent abnormal diastolic filling and also mild to moderate mitral regurgitation so what all that means let me go ahead and tell you about my assessment and plan so for your first problem of your you know congestive heart failure it sounds like this was caused by you know dietary indiscretion in an uncontrolled hypertension so what i wan na do is i want you to continue on bumex two milligrams one daily that's that water pill that you're talking about and then i want you to continue to watch your diet and also avoid salty foods i know you love your pizza and chicken wings but we are gon na have to cut back on those okay kevin
[patient] alright
[doctor] alright now i want you to weigh yourself though everyday and then call me if you gain like three pounds in two days okay
[patient] okay
[doctor] okay now i do want you to see a nutritionist too and give you some education about what foods you can eat
[patient] alright sounds good
[doctor] alright now for your second problem of hypertension i do want you to continue on that cozaar a hundred milligrams daily and then also continue on that norvasc five milligrams once daily and i'm gon na go ahead and order a renal artery ultrasound just to be sure that we are n't missing anything we wan na make sure there's no other causes like secondary causes that that's gon na cause some problems with your with your kidney okay
[patient] okay
[doctor] alright now for your third problem your kidney disease i do want to get some more labs some more blood work to make sure that you tolerate this regimen
[patient] alright that sounds good
[doctor] okay and if do you have any other questions for me
[patient] i do n't think right now
[doctor] okay well then i'll see you again in three months then kevin okay take care of yourself
[patient] alright thanks document
[doctor] alrighty bye | CHIEF COMPLAINT
Hospital follow-up after acute on chronic CHF exacerbation.
MEDICAL HISTORY
Patient reports history of hypertension and stage 3 chronic kidney disease.
SOCIAL HISTORY
Patient reports being a football fan.
MEDICATIONS
Patient reports taking Bumex 2 mg once daily, Cozaar 100 mg daily, and Norvasc 5 mg once daily.
REVIEW OF SYSTEMS
Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Musculoskeletal: Reports bilateral ankle swelling.
Neurological: Denies any sleep disturbance.
VITALS
BP: 128/72.
HR: 79 bpm.
RR: 26.
SpO2: 99%.
PHYSICAL EXAM
Neck
- General Examination: No jugular venous distension noted.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: Regular rate. There is a 2/6 systolic ejection murmur, stable.
Musculoskeletal
- Examination: There is trace edema to the bilateral lower extremities.
RESULTS
Previous echocardiogram is reviewed and revealed a preserved EF of 55% abnormal diastolic filling and mild to moderate mitral regurgitation.
ASSESSMENT AND PLAN
1. Congestive heart failure.
- Medical Reasoning: This appears to be cause by dietary indiscretion and uncontrolled hypertension.
- Patient Education and Counseling: We discussed that he should continue to monitor his diet and avoid salty foods. I advised him to weigh himself every day and call me if he gains 3 pounds in 2 days.
- Medical Treatment: Continue Bumex 2 mg once daily. Referral to nutrition provided for dietary education.
2. Hypertension.
- Medical Reasoning: This was uncontrolled prior to his hospital visit.
- Patient Education and Counseling: We discussed the importance of diet and home blood pressure monitoring.
- Medical Treatment: Continue Cozaar 100 mg daily. Continue Norvasc 5 mg once daily. Renal artery ultrasound ordered for further evaluation.
3. Kidney disease.
- Medical Reasoning: Due to patient's acute CHF exacerbation, this is to be monitored.
- Medical Treatment: Lab work ordered.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up in 3 months. He is advised to call should he experience weight gain of 3 pounds in 2 days. |
D2N162 | aci | [patient] okay
[doctor] hi gregory hi how are you doing today
[patient] good how are you
[doctor] i'm alright so i understand that you were having some you know right ankle pain and some swelling after you fell can you can you tell me a little bit about what happened
[patient] yeah so i was going out to take off the trash and i you know i was icy and i i was being very careful and then i noticed that there must have been a little patch of ice or something because all i know is that i slipped and i was on the ground and i was being really really careful
[doctor] okay yeah i know especially this this winter has been rough so you got ta watch for those little ice patches sometimes well okay so this occurred yesterday after falling on the ice so have you been able to walk on it at all
[patient] when it first happened i could n't and i actually had a friend who was with me he was she was actually coming to visit and so she had to help me up and so last night i was you know keeping it elevated i was resting it icing it so today it feels a little better like i could put a little bit more weight on it but i'm definitely still limping it it's not my normal
[doctor] okay alright and tell me what have you been doing for that foot pain since then
[patient] you know other than the icing i have taken some ibuprofen and i do feel like it's it it is helping
[doctor] okay okay very good alright and tell me have you ever injured this ankle before
[patient] you know considering i do a lot of sports my favorite right now is soccer or my favorite always is soccer and i've had a lot of injury but i ca n't remember if i actually injured this ankle i do n't think i ever have
[doctor] okay alright well good i mean considering how long you've been playing soccer i know you're actually playing for the community league now so that is really great representing the community
[patient] yes it's so much fun
[doctor] yeah and and do your kids come and watch you play
[patient] yeah they come and watch and then now the oldest one is old enough to play himself so they have a leak for four and five -year-olds so he should be starting that soon too so i know he's really gon na enjoy that
[doctor] that's gon na be exciting for him
[patient] so much fun
[doctor] that's a great you had a great soccer league of your own here in your family
[patient] yeah my husband's really into soccer too
[doctor] yeah
[patient] play a lot so
[doctor] oh
[patient] yeah
[doctor] well you i guess you'll be watching it for a while instead of playing it though
[patient] i well i hope not not for too long
[doctor] yeah we'll we'll see what we can do just to get you back out there again okay so tell me have you experienced any kind of numbness in your foot at all
[patient] no not that no i have n't had any numbness
[doctor] okay alright very good well let me go ahead and do a physical exam on you real quick here let me take a look at your vital signs good good everything here looks good lem me go ahead and take a look at your right ankle real quick i'm just gon na pull your pant leg up here and then look look at it now on the skin here there is ecchymosis and that's bruising this bruising gregory and over the lateral malleolus associated swelling now lem me go ahead and just feel around here how does that feel
[patient] that hurts
[doctor] i'm sorry so you definitely there is some tenderness to palpation and anterolaterally in the soft tissue there is no laxity on anterior drawer and inversion stress and there is no bony tenderness on palpation of the foot now i'm just gon na take a look at your right foot here just to make sure it's still intact here so okay good on the neurovascular exam of your right foot your capillary refill is less than three seconds with strong dorsalis pedis pulse and your sensation is intact to light touch so that's good sign now so gregory i did review the results of your right ankle x-ray and it showed no fracture so that's good so let's go ahead and talk about my assessment and plan so for your problem of right ankle pain what i'm seeing is that your symptoms are consistent with right ankle sprain so what i would like to do is i would like you to keep your leg elevated and especially when you're seated and to continue to ice it okay
[patient] okay
[doctor] alright and then you're going to also be given an aircast which is really gon na help stabilize the ankle and then you also be given some crutches for the next one to two days and then you may start walking on it as tolerated
[patient] okay
[doctor] okay
[patient] okay
[doctor] do you have any questions any other questions for me
[patient] so when will i will i be able to play
[doctor] well let's see now your symptoms should significantly improve in the next two weeks and what i'll do is i'm gon na follow up with you then and then see how you're doing okay and then just please continue to take the nsaids as needed to help with any of that pain that you may have okay
[patient] okay
[doctor] and then we will see in in a few weeks how how if you're ready to go play soccer again okay alright
[patient] alrighty
[doctor] well do you have any other questions for me or is there anything else i can do for you
[patient] no i think that's it thank you
[doctor] okay well i will have the nurse check you out and then if you experience any kind of symptoms in the next you know before your next visit with me go ahead and feel free to call the clinic okay
[patient] okay
[doctor] alright alright take care gregory
[patient] alright thank you
[doctor] bye
[patient] bye | CHIEF COMPLAINT
Right ankle pain and swelling.
HISTORY OF PRESENT ILLNESS
Gregory Hernandez is a pleasant 42-year-old male who presents to the clinic today for evaluation of right ankle pain and swelling. The onset of his pain began yesterday after he slipped and fell on the ice while taking out the trash. He states that he was unable to ambulate at the time of injury and that a friend had to help him up. He then proceeded to ice and elevate his ankle throughout the night. His pain has since improved and he is able to bear more weight on his right ankle, however he is still limping. He denies experiencing any numbness to his right foot. In addition to ice and elevation he has been taking ibuprofen for his pain, which has provided some relief. He does not recall any other previous injury to his right ankle.
SOCIAL HISTORY
Patient reports that he is very active and enjoys playing soccer. He currently plays for the community soccer league.
REVIEW OF SYSTEMS
Musculoskeletal: Reports right ankle pain.
VITALS
Vitals signs look good today.
PHYSICAL EXAM
CV: Mild edema
NEURO: Normal sensation.
MSK: Examination of the right ankle: Ecchymosis is present. There is swelling over the lateral malleolus. Tenderness to palpation anterolaterally in the soft tissue. No laxity on anterior drawer and inversion stress. No bony tenderness on palpation of the foot. Neurovascular intact. Capillary refill is less than 3 seconds with a strong dorsalis pedis pulse. Sensation is intact to light touch.
RESULTS
3 views of the right ankle were taken today. These reveal no evidence of fracture.
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 his current symptoms. We discussed that his x-rays did not reveal any signs of a fracture and that he sustained a right ankle sprain. Treatment options were discussed. He was advised to keep his right lower extremity elevated, especially when seated. He will also continue to ice his right ankle. An Aircast was provided today to help stabilize his ankle. He is to also utilize crutches for the next 1 to 2 days followed by weight-bearing as tolerated. For pain control he can continue to take NSAIDs as needed. We discussed that he should see significant improvement in his symptoms over the next 2 weeks.
INSTRUCTIONS
The patient will follow up with me in 2 weeks to assess his progress and to determine his return to play date. He is advised to call the office should his symptoms change or worsen prior to his next appointment.
|
D2N163 | aci | [doctor] julie cruz is a 17 -year-old non- binary immensipated minor with no significant past medical history presents for evaluation of newly diagnosed hypercholesterolemia patient is here at the clinic hi julie how're you doing
[patient] i'm okay
[doctor] so i now i know you're worried about you know what's been happening with your with your you know with your blood cholesterol so can you tell me a little bit more about what's going on
[patient] yeah i mean i'm worried about this finding i went for my annual checkup and they checked my cholesterol one of those finger prick tests and it came back elevated and they told me i should come and see you
[doctor] okay alright well i think it's a good thing that you know we're aware of this elevated cholesterol at a young age and that we can do something about it so lem me ask you julie a couple of questions here okay so what kind of activities do you like to do
[patient] well i really like to go outside i ride my bicycle a lot
[doctor] okay
[patient] which is it's a lot of fun i ride the trails
[doctor] that's fun very nice so you stay pretty active it sounds like
[patient] well i keep pretty active during the week yeah
[doctor] okay very good good for you now tell me what what kind of foods do you like to eat
[patient] well i mean i really like chocolate chip cookies
[doctor] yeah
[patient] i mean i i try to cook pretty much everything is fresh but i i really do like like cookies and i i mean but even after that i mean i i try to eat pretty clean diet most days
[doctor] yeah
[patient] that's why i was really surprised my cholesterol was high
[doctor] yeah okay well we will we will try to look check and see what's going on there okay so so what kind of so have you you've done any fun activities that now that you know it's getting warm out
[patient] yeah i went for a bike ride over the weekend and some friends have morning we we went for a bike ride and then we had a pick
[doctor] that's fun
[patient] it was pretty nice it was a little chilly but it's nice now that it's springtime
[doctor] yeah but yeah that sounds like fun
[patient] it was fun
[doctor] techniques are fun so tell me do you do you have any history at all of you know hypercholesterol serol anemia on the like at a early age any other you know family members that that you remember that may have that problem
[patient] well i do n't really think so i do n't really talk to my parents too much
[doctor] i know
[patient] but i i have a pretty good relationship with my grandparents
[doctor] okay
[patient] you know and i remember talking to my grandmother and my grandfather both and they do n't they said that when they were young they did n't have anything like that so i had mine checked last year and the doctor said it was a little borderline
[doctor] okay
[patient] but it was n't anything to be worried about that time it kinda just blew it off just told me to watch what i was eating and now they say it's really hot and i do n't understand what's going on
[doctor] okay alright okay we'll we'll we'll we'll take a look at that okay now tell me have you had any issues you know with growing growing up bones are feeling okay you feel like you're growing okay
[patient] i i guess so i mean when i met with my doctor i they talked about making health goals and making sure that that i i feel okay and i i decided about two years ago that i i do n't feel much like a girl i it's it's more of just kind of a nongender and that's how i've been living
[doctor] yeah
[patient] and but i mean i thought i was healthy
[doctor] yeah okay well you know we can get you there too you know we can work on that so we we'll take we'll talk more about some tips to help achieve those goals okay
[patient] okay
[doctor] okay and tell me does anyone at home smoke
[patient] well when i used to live with my parents they did but i live on my own now
[doctor] right
[patient] nobody smokes my apartment
[doctor] okay you know if your friends come over if they smoke too or what okay
[patient] nope
[doctor] okay
[patient] no nobody that i spend time with smoke
[doctor] okay now tell me is there any history at all of like maybe heart disease or sudden death you know like early early in those your family's years
[patient] well come to think of it i did have my my grandparents told me that that i had a cousin that died and and he was only like forty four or forty five
[doctor] okay
[patient] they they think that he had a heart attack
[doctor] okay well i'm sorry to hear that okay so that's that's helpful information though okay let's go ahead and do physical exam on you there julie i'm gon na go ahead and take a look at your vital signs looks like your blood pressure looks good so that's good now on your heart exam i do n't appreciate any murmur rubs or gallops on your lung exam your lungs are clear on your eye exam i do n't appreciate any zenthomas and also on your neck exam here there is no thyroid megaly so now on your abdominal exam i do n't appreciate any hepatomegaly or splenomegaly why can i see these today so i reviewed the results of your cholesterol level and it was elevated at two ten so that's high so let me go ahead and tell you about my plan so for your problem of elevated cholesterol what we wan na do is you know the american academy of pediatrics actually recommends that all children be screened screened once you know they become between ages and nine and eleven and then again between ages seventeen and twenty so that's why you were screened okay so we do we yeah so we do this because studies have shown a link between high cholesterol and premature heart attacks so i wan na go ahead and order a full cholesterol panel there could be other reasons that could be causing the the high cholesterol but i'll go ahead also and check some glucose a complete metabolic panel some thyroid studies and liver panels and i wan na perform a genetic testing to see if this problem is familial or this is a secondary cause so we are also gon na go ahead i wan na follow up in a follow-up with a well balanced diet so including a variety of foods that are lower in saturated fat and sugars so i want you to follow that and i want you to meet a nutritionist and so who can give you information about what kind of foods to eat okay
[patient] okay
[doctor] alright now i do want you to continue to be active and exercise so that's great especially that you know your bike riding so you keep that up that's a great thing and you're doing well with that so keep that up for you okay and then i wan na follow up with another cholesterol level in three to six months after you've met with the nutritionist and then and they've you know instituted those dietary changes
[patient] okay it sounds good
[doctor] okay good well take care julie i'll talk to you soon
[patient] alright thanks document
[doctor] thank you bye | CHIEF COMPLAINT
Hypercholesterolemia.
SOCIAL HISTORY
Patient denies any history of smoking; however, they note that their parents smoked when they lived with them. They enjoy being outside and riding their bike on trails.
FAMILY HISTORY
Patient reports a cousin who died of a heart attack in their 40's. but denies any family history of hypercholesterolemia.
VITALS
Blood pressure looks good.
PHYSICAL EXAM
Eyes
- Examination: No xanthomas noted.
Neck
- General Examination: Neck is supple without thyromegaly.
Respiratory
- Auscultation of Lungs: Clear bilaterally.
Cardiovascular
- Auscultation of Heart: No murmurs, gallops or rubs.
Gastrointestinal
- Examination of Abdomen: No hepatomegaly or splenomegaly.
RESULTS
Recent cholesterol level is reviewed and shows patient is elevated at 210.
ASSESSMENT AND PLAN
1. Elevated cholesterol.
- Medical Reasoning: The patient's previous tests are consistent with hypercholesterolemia.
- Patient Education and Counseling: We discussed that the American Academy of Pediatrics recommends children between the ages of 9 to 11 years old and again between 17 to 20 years old be screened for their cholesterol. We also discussed that studies link high cholesterol to pre-mature heart attacks. I advised the patient that genetic testing can be done to see if the problem is genetic or a secondary cause. They were also advised to follow a balanced diet with a variety of foods that are low in saturated fat and sugars, as well as remain active.
- Medical Treatment: Full cholesterol panel ordered. Hemoglobin A1c, CMP, thyroid study, and liver panel were also ordered. Genetic testing ordered. Referral to nutritionist provided.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow-up in 3 to 6 months after meeting the nutritionist for another cholesterol level.
|
D2N164 | aci | [doctor] so elizabeth is a 53 -year-old female today complaining of chest pain and she has a past medical history of diabetes and high blood pressure so elizabeth tell me what's going on with your with your chest pain
[patient] i do n't know every time i start walking i'm just having this kind of pressure and chest pain in my chest
[doctor] okay are you having it now or is it gone right now
[patient] right now it's not there
[doctor] okay and how long have you been having this
[patient] probably maybe three months
[doctor] okay and what seemed to bring it on anything exacerbated or relieve it
[patient] it mainly happens when i'm walking i like to try and walk but lately i just have n't been able to keep up with it because i'm having this pain
[doctor] alright and well how would you describe this pain it's like a dull pain sharp pain stabbing pain how would you describe it
[patient] i would say it's dull it's kinda like a pressure
[doctor] okay and does it go anywhere or radiate any place
[patient] no
[doctor] okay alright but no chest pain right now no shortness of breath no sweats or clamminess or anything like that right now
[patient] nothing right now
[doctor] okay alright well certainly you know i looked at your ekg that did we did in the office when you came in the ekg i do n't see any signs of a heart attack or anything like that so i'm you know we should definitely talk about the plan for this chest pain in a few minutes but right now the good news is i do n't see any signs of a heart attack or anything like that so let's talk a little bit about your other conditions since you are here today how are you doing with your diabetes i know we have you on metformin and we talked about last time about you know improving your diet and exercise i'm glad you're exercising but i'm so sorry to hear about the chest pain so tell me about how is that going
[patient] yeah i mean i think my blood sugars have been a little higher because i have n't been able to be active and i'm trying with the diet you know i do love sodas so i'm really trying strength dose
[doctor] yeah i i am addicted to diet coke myself so i i hear you on that one and we had checked your hemoglobin a1c last time it was you know seven . which is pretty good it's not you know it could be better but it's not it's not bad and we talked about sending you to ophthalmology also for an eye exam have you seen ophthalmology in the last few months or last before i saw you
[patient] i have an appointment in two weeks it was a long waiting
[doctor] okay got it and any nausea vomiting or diarrhea or anything like that with your diabetes or any side effects from your medications the metformin
[patient] no
[doctor] okay alright good and i saw also there was a record in your i was looking at your record before previously before i walked in you also had we've been checking your blood pressure but but i think you've been into several other clinicians and they had documented high blood pressure have you noticed any findings with that or have you know have anybody talked about high blood pressure with you or mentioned that because we do n't have it in our system here yet but i did add it in today but we do n't have you on any medications yet for that
[patient] no i mean i do n't know doc no one told me about high blood pressure do i have high blood pressure
[doctor] well i think the last time you were in the clinic and one of the clinics said the referrals the your blood pressure was elevated so they had mentioned that i noticed a trend in your blood pressure it's been running on a little bit on the high side we have n't really diagnosed you with that yet but i think we are something that we should definitely consider looking at your trend of your blood pressure readings over the last you know a few years
[patient] okay do you think that could be causing me my my chest pain
[doctor] it certainly could be contributing to that it certainly could be a factor that we need to look at so
[patient] someone had told me before
[doctor] yeah me too but we we can we can definitely you know get you started on some monitoring devices for that and also maybe start you on some some diet control things that we can do to help with the blood pressure and maybe start you on some blood pressure medications if we need to okay
[patient] okay sounds good
[doctor] so let me examine you elizabeth for a second for the because we're running out of time here for a second so i'm gon na go ahead and do my exam we got ta just did my magical exam and i'm gon na go ahead and verbalize some of my findings just so i can get it documented in my note okay and i'll explain things as we go along so there is no jvd there is no swelling in your neck there's no carotid bruits your lung exam is clear i do n't hear any crackles or rhonchi your heart exam you do have a two over six systolic ejection murmur you had that in the past otherwise it's regular rate and rhythm your pulses are equal your belly exam is nice and soft your no tenderness no guarding no masses that i can feel on your belly and your back exam is fine your extremity exam you have a little bit of swelling in your lower legs one plus nonpitting edema or swelling in the in your in your ankle area here no calf tenderness so what does all this mean i'll explain that in a second so basically your exam is pretty normal except for you have a little bit of swelling in your legs so you know with this chest pain i'm a little bit so the first diagnosis that we talk about is this chest pain i'm worried about my suspicion is you have something called unstable angina especially considering your history of diabetes and the suspected history of high blood pressure and your family history of of heart disease in the past as well i'm i'm gon na go ahead and refer you to cardiology i reviewed your ekg today so that looks normal so that's good no other signs of a heart attack but i am worried that you may have some sort of a blockage going on that's causing this chest pain i'm gon na go ahead and start you on some aspirin daily i'm also gon na give you a prescription just a baby aspirin you can take eighty one milligrams once a day and also i'm gon na give you a prescription for nitroglycerin it's a it's a little pill you split underneath your tongue if you have this chest pain if it does n't go away after one or two pills i want you to go to the hospital call nine one one and go to the hospital but we will try to get you into cardiology the next week and get you set up for some sort of a stress test to look at your heart okay any questions about that
[patient] so anytime i have a chest pain even if i'm just like walking i have to take that pill
[doctor] yeah if you if you stop walking the chest pain goes away you do n't have to take the pill but if you are walking or you stop and the chest pain does not go away i would take the pill and see if it goes away if it does not
[patient] how long like how long do i wait to see if it goes away
[doctor] about five minutes so you can take it up to three pills every five minutes and if it does n't go away then i would you know go to the hospital and get this checked out because i worry about with this chest pain that you're having making sure it does n't lead to a heart attack those chest pain could be a you know a a a sign that you may be having some less blood flow to your heart and we need to get that checked out pretty quickly
[patient] okay
[doctor] alright
[patient] mm-hmm
[doctor] and for the second problem the diabetes you know i think you're doing fairly well continue with your eye ophthalmology appointment you have for your eye exam for the diabetic retinopathy continue the metformin five hundred milligrams twice a day i'm gon na order another hemoglobin a1c today and i'm gon na have you come back in about two weeks and we can see if we need to make any adjustments continue to try to stay away from you know the the pop and the sweet things and once we have your heart taken care of or make sure your heart is okay you can and we can hopefully resolve this chest pain that you're having get back to your exercise regimen okay any questions about that
[patient] no
[doctor] okay and for the third diagnosis the high blood pressure you you do have a trend i've noticed in your chart that your blood pressure's been running a little bit high several other people have documented as well i'm gon na go ahead and start you on some hydrochlorothiazide it's a pretty low dose medication to help you with your blood pressure plus it'll also help with you some of the swelling you have in your in your feet i'm gon na have you use a blood pressure cuff at home and enter your findings at epic mychart and i'll get a reading of those as well and then what when you come back in two weeks we'll keep a log of your blood pressure daily in the morning when you wake up and see how things are going and then if we need to make any adjustments to the medications we can but especially considering your history and the chest pain and the diabetes and the swelling i think starting this hydrochlorothiazide is a probably a good idea
[patient] okay are there any side effects with this medication
[doctor] yeah it can cause sometimes it can cause a little bit of make you go to the bathroom a little bit more often in the evening but generally most people do n't have a whole lot of side effects i'll give you a handout of the side effects but sometimes you can have a cross reaction with some other medications like sulfa medications but generally most people tolerate this pretty well
[patient] okay
[doctor] alright any other questions we got
[patient] that's it
[doctor] alright well great seeing you thanks for coming in today
[patient] thank you appreciate it | CHIEF COMPLAINT
Chest pain on exertion.
MEDICAL HISTORY
The patient has a medical history of diabetes type 2. She has not been formally diagnosed with hypertension, but her blood pressures have been trending high.
FAMILY HISTORY
Patient reports family history of heart disease.
MEDICATIONS
Patient reports taking metformin 500 mg twice daily.
REVIEW OF SYSTEMS
Constitutional: Denies diaphoresis or clamminess.
Cardiovascular: Reports chest pain.
Respiratory: Denies dyspnea.
Gastrointestinal: Denies nausea, vomiting, or diarrhea.
PHYSICAL EXAM
Neck
- General Examination: No JVD, swelling, or carotid bruits.
Respiratory
- Assessment of Respiratory Effort:
- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.
Cardiovascular
- Auscultation of Heart: 2/6 systolic ejection murmur, otherwise normal rate and rhythm. No murmurs, gallops or rubs. Pulses are equal.
Gastrointestinal
- Examination of Abdomen: No masses or tenderness. Soft, no guarding.
Musculoskeletal
- Examination: 1+ nonpitting edema in the ankles. No calf tenderness.
RESULTS
EKG was obtained and reviewed in office today and is unremarkable. Hemoglobin A1c: 7.0
ASSESSMENT AND PLAN
1. Chest pain.
- Medical Reasoning: Considering her history of diabetes, possible history of hypertension, and family history of heart disease, I suspect her chest pain is likely unstable angina. Her recent EKG was unremarkable and there are no other signs of heart attack, but I am worried she may have some sort of a blockage causing her pain.
- Patient Education and Counseling: We discussed proper protocol for sublingual nitroglycerin for chest pain. I advised her to go to the emergency department if the medication is not effective after approximately 5 minutes.
- Medical Treatment: We will have her start a regimen of baby aspirin at 81 mg daily, for which I have sent in a prescription today. I also sent a prescription for nitroglycerin up to 3 tablets every 5 minutes as needed. Finally, I am going to have her follow up with cardiology for further evaluation.
2. Type 2 diabetes.
- Medical Reasoning: She appears to be doing well on her current regimen.
- Patient Education and Counseling: I encouraged the patient to keep her appointment with ophthalmology for evaluation of diabetic retinopathy.
- Medical Treatment: I'm going to put in an order for a repeat hemoglobin A1c to check for any needed medication adjustments and have her follow up in 2 weeks. In the meantime, I want her to continue with metformin 500 mg twice daily and dietary modifications.
3. Hypertension.
- Medical Reasoning: Several providers, including myself, have noted a trend of elevated blood pressures in the patient's chart.
- Patient Education and Counseling: I advised the patient to monitor her blood pressures at home over the next 2 weeks and report her readings to me via MyChart. This should help us determine if any adjustments need to be made to her new medications. We discussed the possible side effects of hydrochlorothiazide how this will hopefully reduce some of her swelling seen on physical exam. All of her questions were answered.
- Medical Treatment: I'm going to have her start hydrochlorothiazide at a low dose.
Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
The patient will follow up in 2 weeks. |
D2N165 | aci | [doctor] hey sophia how are you doing today
[patient] i've been better my primary care doctor wanted me to see you because of this knee pain that i've been having for about six months now
[doctor] okay do you remember what caused the pain initially
[patient] you know i really ca n't recall any specific event that caused the pain
[doctor] alright well can can you describe the pain for me
[patient] yeah so it's it's like a deep achy pain that it i feel like it's behind my kneecaps and sometimes i can even hear like what seems like like some creaking in my knees
[doctor] hmmm alright now tell me what what type of activities makes that pain worse
[patient] so i feel like the pain gets worse anytime i'm like getting from like a seated position to standing so i i work from home so i'm at my desk a lot so anytime i get up i have some pain or after watching tv or even like going up and down stairs it's really painful
[doctor] hmmm okay and does anything make the pain feel better
[patient] usually after i rest it for some time it does help with the pain
[doctor] okay now you did mention earlier that you have tried some things in the past can you tell me what they were
[patient] yeah so when it first started hurting i was putting ice on it and i even got like some ace bandage like wrapping from the pharmacy i do take ibuprofen or aleve sometimes but i try to avoid really taking any medications
[doctor] okay and and tell me what is your day like
[patient] well i try to be as active as i can i actually love to run and i would run like five to six miles a day but now i i mean honestly i ca n't even get to half a mile and my leg will start hurting my knee will start hurting
[doctor] okay that's definitely a decrease in your mileage there where have you been running lately like do you run outside or on a treadmill or
[patient] yeah i i you know i will do the treadmill during the winter but i just love being outdoors and running
[doctor] yeah yeah there are some really nice senior routes here in boston is n't there like
[patient] there are
[doctor] so many knee places there's some right by the harbor that i've i've done some runs there before too it's pretty nice well i mean the boston marathon what can you say right
[patient] right exactly exactly no it's very nice
[doctor] well okay well hopefully that we get you feeling better so you can start running again more than . five miles but tell me though have you noticed any swelling or redness in your knees
[patient] no not really
[doctor] okay and have you ever injured your knees before
[patient] no i've been pretty good i actually have never broken a bone actually no i'm gon na change that actually i did break my arm when i was in sixth grade but nothing since then
[doctor] okay
[patient] i
[doctor] okay and it's just your arm right not not your knee
[patient] right
[doctor] okay well alright well let's go ahead and do a quick physical exam on you here let me look at your vital signs okay i reviewed your vitals they they overall they look good take a listen to your heart real quick alright and your heart exam i hear regular rate and rhythm with no murmurs and on your musculoskeletal exam i have seen you and walk around here and you do have normal gait alright now i'm gon na have you do some movements on your legs here okay
[patient] okay
[doctor] alright good your strength is three out of five for abduction of legs bilaterally and the remainder of muscle strength for your lower extremities are five out of five so that's good let me take a look at your knee now on your knee exam there is no overlying erythema that's redness or ecchymosis and that's bruising or any warmth of the skin appreciated there is no effusion let me go ahead and feel around here does that hurt right here how does that feel
[patient] it does
[doctor] sorry so there is tenderness to palpation of the bilateral retinacular retinaculum and there is positive patellar grind test alright and can you are you able to squat for me
[patient] i can but that hurts
[doctor] okay alright so you're definitely having some knee pain with squatting and i'm just gon na maneuver your leg just a little bit here real quick okay so lachman anterior and posterior drawer and mcmurray tests are all negative bilaterally so that's good there okay now your neuro exam patella and achilles reflexes are symmetrical alright so now i did review the results of your x-ray and both of your knees which shows no fractures or osteoarthritis so let me go ahead and tell you about my assessment and plan so for your problem of bilateral knee pain based on what you told me your exam and reviewing your mri your symptoms are consistent with patellofemoral pain syndrome and this is a very common condition that we see that causes knee pain especially in active young people so this condition has to do with the way your kneecap which is your patella how that moves along the groove of your thigh your thigh bone which is the femur now for the pain you may continue taking ibuprofen or anti-inflammatory as needed to help with the pain but i'm also going to recommend physical therapy where where they will show you a number of lower extremity exercises and this will help increase your lower extremity strength your mobility and correct any incorrect running mechanics that you may have so do you have any questions for me about that
[patient] will i be able to run anytime soon
[doctor] well that is a goal of treatment and to get you back in running again now you will have to take an take it easy from running for now but we will continue to assess your progress with each visit okay
[patient] okay
[doctor] alright anything else
[patient] no i think that's it
[doctor] okay well very good well i will be following up with you soon and again just take it easy for now from the running okay
[patient] okay thank you
[doctor] bye
[patient] bye | CHIEF COMPLAINT
Bilateral knee pain.
HISTORY OF PRESENT ILLNESS
Sophia Jackson is a pleasant 30-year-old female who presents to the clinic today for the evaluation of bilateral knee pain. She was referred by her primary care provider. The onset of her pain began 6 months ago. She denies any specific injury. The patient describes her pain as a deep, achy pain. She locates her pain to the posterior aspect of her patellae. The patient also reports “creaking” in her knees. She denies any swelling or redness in her knees. Her pain is aggravated by transitioning from a seated position to standing as well as ascending and descending stairs. Her pain is alleviated by rest. The patient has been icing her knees and wrapping her knees with an ACE bandage. She also takes ibuprofen or Aleve occasionally for pain. She states she tries to be as active as she can. She enjoys running outdoors. The patient adds that she would run 5 to 6 miles per day; however, she is unable to go 0.5 miles secondary to the pain. She denies any previous injuries to her knees.
She works from home.
MEDICAL HISTORY
Patient reports history of an upper extremity fracture when she was in 6th grade.
REVIEW OF SYSTEMS
Musculoskeletal: Reports bilateral knee pain and crepitus. Denies swelling or redness in the bilateral knees.
VITALS
All vital signs are within the normal limits.
PHYSICAL EXAM
GAIT: Normal, no deformity present.
CV: Auscultation of Heart: Regular rate and rhythm. No murmurs.
No edema
NEURO: Patella and Achilles reflexes are symmetrical.
MSK: Examination of the bilateral lower extremities: Abduction strength is 3/5. Remainder of muscle strength is 5/5. Examination of the bilateral knees: No overlying erythema, ecchymosis, or warmth of the skin appreciated. No effusion. Tenderness to palpation of the bilateral retinaculum. Positive patellar grind test. Knee pain with squatting. Negative Lachman test bilaterally. Negative anterior and posterior drawer tests bilaterally. Negative McMurray test bilaterally.
RESULTS
X-rays of the bilateral knees were reviewed today. These demonstrate no evidence of any fractures or osteoarthritis.
ASSESSMENT
Bilateral knee patellofemoral pain syndrome.
PLAN
After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding her current symptoms. I have explained to her that her symptoms are consistent with patellofemoral pain syndrome. We discussed treatment options and I have recommended that we begin with conservative treatment in the form of formal physical therapy to increase her lower extremity strength, mobility, and correct any incorrect running mechanics. I encouraged her to take running easy for now. She can continue taking ibuprofen or anti-inflammatories as needed for pain. All questions were answered.
INSTRUCTIONS
The patient will follow up with me soon. |
D2N166 | aci | [doctor] hey kyle so i see here on your chart that you've been having some back pain could you tell me like how you've been doing what's going on
[patient] yeah i have this real bad low back pain it started a couple of weeks ago i was lifting something and i just felt a pop and i i do n't know what's going on
[doctor] okay and so you were like moving what what were you moving exactly when you say lifting
[patient] i was lifting a box of books
[doctor] okay
[patient] yeah
[doctor] alright did we use proper lifting technique do you wonder
[patient] you know probably not
[doctor] okay alright i'm sorry about that alright can you describe the pain for me
[patient] yeah i i feel like kind of it's like achy and sharp
[doctor] oh
[patient] in in my low back
[doctor] uh uh and does the pain like radiate anywhere
[patient] you know it did n't at first but now i'm feeling it's kinda starting to shoot down my left leg
[doctor] okay alright and how is positioning for you does any sitting in any particular position hurt more or hurt less
[patient] no sitting is usually okay for me
[doctor] mm-hmm okay and then do you have any numbness or tingling associated with the pain
[patient] no
[doctor] okay alright any loss of sensation
[patient] no
[doctor] okay how yes sir okay how about any weakness
[patient] no i do n't feel any weakness
[doctor] okay and i know this sounds like a weird question but i do need to know do you experience any loss of control of your bladder or bowels
[patient] no
[doctor] alright this this is a no judgment zone i there i'm working through some things in my head to make sure that i give you the best care that we need right i'm making a plan as we move along you mentioned that the pain has been getting worse have you done anything or tried anything that's worked in the past
[patient] i tried to take some ibuprofen and tylenol
[doctor] mm-hmm
[patient] that that sometimes helps
[doctor] okay alright and has anyone discussed the option of like just no has anyone discussed surgery with you
[patient] no this is the first time i'm talking about it
[doctor] okay alright that's good so what is your like how what is your activity level right now that i know that you're you know an olympic weightlifter with books what else do you do to like exercise
[patient] you know i try to exercise a few times a week but i'm pretty inconsistent i have a sedentary job
[doctor] okay alright and has this like pain started to like affect you like in your job or anything like that
[patient] not my job but i feel like i do n't want to be as active as i was previously
[doctor] alright so do you have any family members that have spine conditions
[patient] yeah my dad has back pain
[doctor] okay alright and then do you smoke
[patient] i do n't smoke
[doctor] okay awesome alright so sorry one question did you do you have a history of playing sports
[patient] yes
[doctor] okay what did you play
[patient] soccer
[doctor] okay what position
[patient] i played midfield
[doctor] okay the people who hide in the back that's fine i was centered forward fine no baby do you have a team that you wrote for
[patient] you know i am a tatnham hotsper fan
[doctor] they have the best colors not going to lie but i i grew up manu so sorry
[patient] well i wo n't fault you for that
[doctor] thanks okay so if you do n't mind i'm gon na go ahead and do my physical exam i'm gon na call out my findings just to have them recorded and if you have any questions please feel free to stop me and let me know okay
[patient] okay
[doctor] alright so looking at your vitals your blood pressure seems alright we are in like the one thirty over seventy range that's perfectly fine your respiratory rate i have you at an eighteen again pretty normal when i listen here to your heart you have a regular rate and rhythm i do n't appreciate any murmurs rubs or gallops that means your heart sounds great on your respiratory exam your lungs sound clear to auscultation bilaterally on your musculoskeletal back exam as i'm looking here i do n't notice any overlying redness or bruising on the skin when i push here on the midline of your back does it hurt
[patient] yes
[doctor] okay so there is midline tenderness at the l4 l5 disk space with right sided lumbar paravertebral tenderness alright so are you able to bend forward
[patient] yes
[doctor] alright and are you able to bend backward
[patient] yes
[doctor] alright do either of those actions cause you pain
[patient] bending forward
[doctor] okay so pain with lumbar flexion and so i'm gon na have you lie down and we're gon na do i'm sorry okay and then i see that a supine straight leg test is positive alright so for your neurological exam you said that you are experiencing pain radiating down radiating down your left leg correct
[patient] yes
[doctor] alright when i touch are there any like decreased sensation
[patient] no
[doctor] okay alright so patella and achilles reflexes are symmetrical alright so i received before you came in here we got an mri and so in reviewing your results it does show a disk desiccation a disk bulge with paracentral disk herniation resulting in moderate right neuroforaminal i do n't like this word neural foraminal stenosis what those complicated words is that i just said is that it seems that you have a a a herniated disk with nerve impingement so let's talk about my assessment and plan alright your symptoms are in line with a i'm sorry you have lumbar back pain at the l4 l5 disk space due to a herniated disk with radiculopathy this means that one of your disks that sits between your vertebrae like the bones in your spine is bulging out and the bulge is pinching on some nerves so that's why you are feeling that pain like radiating down your leg i'm gon na recommend something a spinal injection with a strong nsaid and called the i'm sorry and a corticosteroid i'm just gon na inject it into the lumbar spine under fluoroscopy which you can think of like an x-ray to localize the exact area of your pain this should help with the inflammation that's causing your pain i know that sounds a bit scary it this is a typical procedure that i do all the time it's in office and we can get you scheduled today if you would like so what questions do you have right now
[patient] is that something that we can do today
[doctor] yeah i think i have time in my schedule to get it done today just you know i'm here for you right now
[patient] alright
[doctor] okay
[patient] are there are there any complications with this
[doctor] there are sorry yeah you're right there are risks associated with this kind of injection just like any procedure but we aim to minimize them and my ma when she comes in we will give you some paperwork with explanations and any and hopefully answer most of the questions that you have if after reading that you have any more questions please feel free to stop us we want to make sure that you feel as comfortable as possible during this time
[patient] okay
[doctor] alright
[patient] great
[doctor] anything else
[patient] i think that's it
[doctor] alright | HISTORY OF PRESENT ILLNESS
Kyle Morales is a pleasant 58-year-old male who presents to the clinic today for the evaluation of low back pain.
Onset of his pain began 2 weeks ago, when he was lifting a box of books and felt a pop. The pain is described as aching and sharp. His pain has been increasing since the time of onset and is beginning to radiate down his left leg. The patient denies any pain with sitting. He adds that he has a sedentary job. The patient states that his pain does not affect his job, however he feels that he does not want to be as active as he was previously. He tries to exercise a few times per week, however he is inconsistent. He denies any numbness, tingling, loss of sensation, weakness, and loss of control of his bladder or bowels.
The patient has been taking ibuprofen and Tylenol for pain, which provides some relief. He has not been evaluated for surgery.
SOCIAL HISTORY
He denies smoking. The patient has a history of playing soccer in the midfield position.
FAMILY HISTORY
The patient states that his father has back pain.
REVIEW OF SYSTEMS
Musculoskeletal: Reports low back pain.
Neurological: Denies bowl or bladder control issues, numbness, tingling, decreased sensations, or weakness.
VITALS
Blood pressure: 130/70 mm Hg.
Respiratory rate: 18.
PHYSICAL EXAM
CV: I do not appreciate any murmurs, rubs, or gallops.
RESPIRATORY: Normal respiratory effort no respiratory distress. Clear to auscultation, bilaterally.
BACK: No evidence of trauma or deformity
NEURO: Normal sensation. Patellar and Achilles reflexes are symmetrical.
MSK: Examination of the lumbar spine: No ecchymosis noted. Midline tenderness at the L4-5 disc space with right-sided lumbar paravertebral tenderness. Pain with lumbar flexion. Positive supine straight leg test.
RESULTS
The MRI of the lumbar spine was reviewed today. It revealed disc desiccation and a disc bulge with a paracentral disc herniation resulting in moderate right neural foraminal stenosis.
ASSESSMENT
Lumbar back pain at the L4-5 disc space due to a herniated disc with radiculopathy.
PLAN
After reviewing the patient's examination and MRI findings today, I have discussed with the patient that his MRI revealed a herniated disc with radiculopathy. We discussed treatment options for this and I have recommended that we begin with conservative treatment in the form of a corticosteroid injection. With the patient's consent, we will proceed with a corticosteroid injection into the lumbar spine today. The patient was made aware of the risks of bleeding, infection, nerve damage, blood vessel damage, reaction to the medication, including skin changes, swelling, and also, the risk of elevated glucose levels if the patient were diabetic. |
D2N167 | aci | [doctor] angela good to see you today so i'm writing here in my notes that you're you're coming in you had some left knee pain so how did you hurt your knee
[patient] yeah so i hurt my knee the other day when i was running around with my niece she she is learning how to take off the training wheels for her bike
[doctor] mm-hmm
[patient] and i fell and i think i twisted my knee in some kind of funky way
[doctor] okay that that that that's not good how old are your niece
[patient] she is five and perfect
[doctor] well that's good that you're trying to help her with the learning how to ride a bike
[patient] yeah
[doctor] that sounds fun but i'm i'm sad as you hurt your knee doing it so for your knee pain are you are you able to bear weight on that leg the left leg
[patient] well i've been limping ever since and it really has n't gotten better so i thought it was maybe time to come see you because it happened about a week ago
[doctor] yeah yeah it's a definitely a good time to come see me so what part of your knee would you say it hurts
[patient] honestly it's been hurting on both sides more so on the inside than the the outside
[doctor] so okay so more in the medial aspect less on the lateral okay that makes sense and you said did you hear a pop when you when you twisted it
[patient] yeah i did
[doctor] okay alright so how would you rate your pain with your knee out of out of one to ten
[patient] it started off as like a four but i think it's getting worse and it's starting like it's it's like a like a throbbing kind of pain yeah
[doctor] alright and have you taken anything for the pain
[patient] yeah so i i had like a ulcer not too long ago so my doctor told me that i could n't take any like kind of advil or ibuprofen
[doctor] mm-hmm
[patient] so i've been taking some tylenol and i wrapped it with kinesiology tape are you familiar with that
[doctor] yep yeah i'm i'm familiar
[patient] okay
[doctor] alright and has the has the ibuprofen been helping you at all
[patient] i ca n't take ibuprofen
[doctor] i mean i'm sorry the tylenol
[patient] no it's okay but the tylenol it helps like a little bit but you know like it's it's got like a time limit right so by the time and i'm not supposed to take it like more than like every like four hours or something like that but by hour or two like it it hurts again
[doctor] okay yeah that yeah you ca n't take too much of that tylenol because it'll it'll mess up your liver definitely
[patient] right
[doctor] alright so go ahead and do a quick exam on your knee here so when i press here does that hurt
[patient] yeah like when you press on the inside that hurts a lot
[doctor] okay alright i'm gon na do a couple of other other maneuvers here for your knee so on your left knee exam i do appreciate some edema you also have some effusion some fluid in the knee you have moderate range of motion so you're able to move it a little bit but not all the way i also see you have some pain on flexion and extension of the knee even negative lachman's test and a negative valgus and varus test as well so all that to say is i do n't think anything is is torn in your knee based on the your physical exam so we did do a x-ray of your left knee and luckily it was normal so there is no fractures no bony abnormalities so everything is good there so let me talk to you little bit about my assessment and plan for your knee okay
[patient] yeah
[doctor] alright so for your your left knee pain i believe you you have a mcl strain or a medial collateral ligament that's the inside of your knee i think when you were running with your knee she had somehow twisted it and so you strained that ligament there so for that what i want to do i'm going to give you some pain medication that's not an nsaid so i will put you on some tramadol you can take fifty milligrams you can do that twice a day and then you can take that tylenol as needed for breakthrough pain alright i'm gon na put you in a knee immobilizer leg knee immobilizer and you can wear that for the next week i just wan na keep the knee from moving so it can heal a little bit and reduce some of the inflammation that you're seeing here and i also want you to ice it and you can do that three or four times a day for twenty thirty minutes at a time and that should help some of that swelling as well and i i you know i know your niece is gon na be upset but i just do n't want you to be running probably for the next three weeks with her just to help us get time to let allow the knee to heal so how does that sound
[patient] that's alright how long do you think it'll be before i can like run or something like that
[doctor] hmmm i think you'll be back to normal in about a month the strain does n't seem too bad but we just need to get you off of the knee so we can allow it to heal i mean once we do that you know along with you know the icing the mobilization and you taking the medication i think you'll be good to go in a month if you do feel like you're getting a little bit worse please feel free to call the office and we can get you in and possibly do more imaging such as an mri to you know to see if it's anything worse but i do n't think it is but just let us know how you feel in a couple of days
[patient] okay alright thanks
[doctor] alright any other questions
[patient] no that's it
[doctor] alright great thanks | HISTORY OF PRESENT ILLNESS
Angela Powell is a pleasant 81-year-old female who presents to the clinic today for the evaluation of left knee pain. The onset of her pain began 1 week ago, when she was running around with her niece and fell. At the time of the injury, she heard a pop and believes that she twisted her knee. She reports that she has been limping since the injury. The patient locates her pain to the medial and lateral aspects of her knee. She rates her pain level as a 4 out of 10, however this is increasing. Her pain is described as a throbbing pain. The patient has been taking Tylenol, which has provided mild and temporary relief, as well as wrapping her knee with kinesiology tape. She states that she is unable to take ibuprofen secondary to an ulcer.
PHYSICAL EXAM
MSK: Examination of the left knee: Edema and effusion noted. Moderate ROM. Pain with flexion and extension of the knee. Negative Lachman's. Negative valgus and varus stress test.
RESULTS
4 views of the left knee were taken. These reveal no evidence of any fractures or dislocations. No other abnormalities are noted.
ASSESSMENT
Left knee pain, possible MCL strain.
PLAN
After reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays did not reveal any signs of a tear. I have recommended that we treat the patient conservatively. The plan is to place the patient in a knee immobilizer to provide increased support for the next week. I have also prescribed the patient tramadol 50 mg to treat her pain. She can take Tylenol as needed for breakthrough pain. I have also advised her to ice her left knee 3 to 4 times a day for 20 to 30 minutes at a time. I have advised her to refrain from running for the next 3 weeks. If her pain does not improve with the immobilizer, I will recommend obtaining an MRI.
|
VS006 | virtscribe | [doctor] next patient is christine hernandez . date of birth is january 13 , 1982 . hey miss christine , how are you doing today ? [patient] i'm good , thanks , how are you ? [doctor] i'm pretty good . so it looks like you've completed the covid vaccine , that's great . [patient] yes , i did . [doctor] anything new since your last visit ? [patient] no , i did all the tests that you had recommended me to take . i have n't been able to take the thyroid medicine . the one that you prescribed as i'm still taking my old one , the price is a little high on the new one . [doctor] okay , so did , did you try the coupon that i gave you ? [patient] i did not try the coupon . there was a charge of $ 75 . [doctor] okay , well , next time that , that coupon should help , but it should only be about three dollars . [patient] okay . i do n't have it . do you happen to have another one you can give me ? [doctor] yep , right here . [patient] wonderful . thank you so much and and then the gel they are charging me $ 100 for it , so i do n't know if this is because it's a , it's walmart or if i should try somewhere else or maybe you know how or where i could get it cheaper . [doctor] yeah , let's try something else . sometimes it can be cheaper if we just prescribe you the individual ingredients of a medication rather than the , the combined medication itself . [patient] that would be great . [doctor] so that's clindamycin gel and benzoyl peroxide maybe by doing them separately , they could be a lot cheaper so that we can do , the unithroid with the discount code should only be about nine dollars for 90 days . [patient] okay , that would be great , yeah , they were charging me $ 75 and i just could n't pay that . [doctor] maybe we try a different pharmacy as well . [patient] okay . so do you think that my weight gain could have been the birth control that i was taking before that caused it ? [doctor] maybe . i do n't really see an endocrine cause for it at least , so i would need to see the , the hyper and dragonism or high testosterone or a high dhea to cause acne or hair growth or any of that stuff , but the numbers are n't showing up out of range . [patient] okay . [doctor] i really do n't see any endocrine cause for it , like i said , your growth hormone was fine , but we definitely want to and need to treat it i do n't know if we talked about maybe a little weight loss study . [patient] you mentioned the weight loss study and you mentioned that i have some meal plans that you had given me , i still have those two . [doctor] have you tried to make any changes in the diet since the last time we spoke ? [patient] i've been trying to get better . i will start back at the gym in july because of my contract , i had to put a hold on it until then . [doctor] okay . [patient] so i do want to start doing that . i will be a little freeer since i'll be on vacation after july 8 . [doctor] okay , good . [patient] and then my cousin was telling me to ask you about cla because it's supposed to help your metabolism , is that okay to take ? [doctor] i'm not sure , what is the cla ? [patient] i'm not sure what it is either . [doctor] okay , well , i'm unfamiliar with it , so . [patient] okay . i also have a coworker who has a thyroid issue too and she suggested to try chromium for weight loss . [doctor] so that likely will not help too much . you could try it either if you really want to but then they will not accept you into the weight loss study if you try those two . [patient] okay . [doctor] chromium is just a supplement and it wo n't help that much . [patient] it wo n't , okay , thank you . [doctor] it wo n't hurt like i should n't say that it wo n't hurt , but it also wo n't help that much , so it's up to you . [patient] okay and so my cousin also suggested amino acids and that i might find them in certain foods i guess for my workout . [doctor] yeah , amino acids are fine , they wo n't , wo n't really help with weight loss either , but it might help you replenish and just kind of feel hydrated . [patient] okay , are they proteins , my cousin said she had lost some weight and has been working out every day but she does n't work , so i do n't know . [doctor] yes , i mean acids are what make up the protein , which is in any food you eat with any protein , so meat , dairy , nuts , any of that sort of thing . [patient] okay , thank you , got it . [doctor] alright are you allergic to any medications ? [patient] no , not that i know of . [doctor] okay . is your skin pretty sensitive ? [patient] yes . [doctor] alright . [patient] yeah , on my sides , i will start getting rashes with different products . [doctor] and have you ever tried clindamycin topical as an antibiotic for your acne ? [patient] no , i've never tried anything for it . [doctor] okay . we may give you some of that . [patient] okay and i also want to mention that my feet do swell up a lot . [doctor] okay . i'm , i'm gon na take a look at that for just a moment . any constipation ? [patient] yes , i also do have that problem . [doctor] alright . miralax will definitely help with that . [patient] okay , yes , my doctor did also recommend that . [doctor] great . alright , let's do an exam real quick . please have a seat on this table and i'm gon na listen to your lungs and heart . [patient] okay . [doctor] alright . deep breath , alright again . [patient] okay . [doctor] alright sounds good . [patient] great . [doctor] let me take a look at your feet and ankles . [patient] okay . [doctor] alright , they look okay right now . certainly let your doctor know about this if it gets any worse or reoccurs . [patient] okay , i'll do that . [doctor] now let's go over your lab work . so when you took that pill , the dexamethasone test , you passed , which means you do n't have cushing syndrome on that test at least . the salivary cortisol though unless you did one wrong , two of them were completely normal , one was abnormal , so we might need to repeat that in the future . [patient] okay , that's okay . [doctor] alright , so your cholesterol was quite high , the total cholesterol was 222 , good cholesterol was about 44 , the bad was 153 and it should be less than 100 . the non-hdl was about 178 and it should be less than 130 . the good cholesterol should be over 50 and it was 44 . so your screening for diabetes is was fine . you do have a vitamin d deficiency and i do n't know if we started the vitamin d yet or not . [patient] yes , we did . i , i do need to take one today though . [doctor] okay . so i also checked a lot of other pituitary hormones , iron levels , everything else seemed to be pretty good and in decent range . [patient] okay , that sounds great . so i wanted to also show you my liver enzymes because i have n't come back since then , but i was also happy because one of them was back to normal . [doctor] okay , great . let's see them . [patient] okay , so the one that's 30 that was almost 200 , not so long ago . [doctor] yeah , your alt was about 128 . [patient] okay and , and back in october it was 254 . [doctor] yeah , this is much better . [patient] okay , great , and then it dropped in january and then it dropped a little more in march since i stopped taking the medicine in december . [doctor] okay , that's good . so i'm proud of you with the course of your labs so before i forget , i'm gon na just put your labs into the computer today and i wo n't be checking your vitamin d level for some time . [patient] okay . so with the thyroid and the low vitamin d , does that always happen together ? [doctor] i do have a lot of people that have thyroid thyroid issues and they have vitamin d deficiency . [patient] okay . [doctor] this is what i'm , i'm going to do , i'm going to put , print out your prescriptions so you can shop around at the pharmacies and see if you can find better prices . [patient] okay , that way i can go ask them and try cvs . [doctor] yeah , that sounds like a plan . [patient] okay , good . so the weight loss study that you mentioned , when does that start or how does that work ? [doctor] so we are about to start as we just got approval last week and we are just waiting on our paperwork , so we can get started . [patient] okay and what's involved with that ? [doctor] so it'll involve you receiving a medication , which has been used for diabetes treatment , and it works mostly in the gut on satiety or satiety hormones . the most common side effects are gon na be nausea , vomiting , diarrhea , and constipation , there are six arms to the study , one is the placebo , the other ones are various , various dosages of the medication , excuse me , you would receive an injection once a week also keep in mind that most of the weight loss medications are not covered by insurance . [patient] okay . [doctor] so it's a way of getting them but the odds of getting one of the arms with the medication that are in your favor right might be only 1 out of 5 of our 100 patients that we have on the list for the study that will receive the placebo . [patient] okay . [doctor] does that make sense ? [patient] yes , it does . [doctor] so we do expect pretty big weight loss because of what we learn in the diabetes study , so it's a year long process and it's an injection once a week . you come in weekly for the first four or 5 weeks , i believe and then after that it's once a month . you do get a stype in for participating in the study and parking is validated and whatever else that you need for the study . [patient] okay , do you know how much the skypond is ? [doctor] i will have to double check for you and you do n't have to be my patient , you just have to meet the criteria so the criteria is a bmi greater than 30 if you do n't have any other medical condition or a bmi greater than 27 if you do have other medical condition like your cholesterol bmi greater than 27 would qualify you . [patient] i have a friend who might be interested and she does have diabetes . [doctor] if she has the diabetes , then she wo n't qualify . [patient] okay . you ca n't if you , if you have diabetes , got it . [doctor] correct . yeah , the only thing that they can not have really is diabetes , severe psychiatric disease or schizophrenia , bipolar , things like that . [patient] okay . [doctor] but if they have hypertension , high cholesterol , things like that , they can definitely sign up . [patient] and they can , okay , thank you for explaining that . [doctor] of course , so do you want me to try to get you into that study or would you just like to try me to prescribe you something , it's kinda up to you . [patient] i think i'll just wait for a little bit now . [doctor] alright . sounds good . i'll give you the information for the research . it's just in my office . it is a different phone number though so then if you're interested , just call us within a month because i do n't know how long the , the wait will be . [patient] okay , we will do . [doctor] perfect . so let me go grab your discount card for the unithroid . when you go in to activate it , the instructions are on this card and then you use your insurance . then show them this and ask how much it will cost . if it's too expensive , just let me know . [patient] i will , thank you so much for your help on that . [doctor] you're welcome . then what i did is i gave you a topical antibiotic plus i gave you the benzyl peroxide so the peroxide may bleach your sheets . but you want to make sure to take it and apply it at night so you do n't have a reaction from the sun during the day . [patient] okay , i can do that . [doctor] but you do also want to make sure that you do n't mess up your sheets . [patient] okay , sounds good . [doctor] so that's that and then let's see how you do on the other medications . i think this will , this will get better . in the meantime , a low carb diet , avoid alcohol and fatty foods and low cholesterol foods . [patient] okay . [doctor] and again once you finish your dose of vitamin d for the vitamin d deficiency , you're gon na start with the 2000 international units daily so that you're able to maintain those levels , sound good ? [patient] yes , that sounds great . [doctor] i really think your liver enzymes are gon na get better once you lose the weight though . [patient] okay , that would be great . [doctor] since we stopped your birth control , we can try one called fexie , which is kind of like a spermaside basically . [patient] okay . [doctor] and you just apply it before intercourse . [patient] okay . [doctor] if you need some just let me know . [patient] okay , i will , i will let you know . [doctor] okay , perfect . so stay put for me now . i'm gon na go see if they have a discount samples and bring you that prescription and then i'm going to order the labs for next time . [patient] okay , great . thank you so much . [doctor] you're welcome . so under the plan under abnormal liver enzymes , they have improved since discontinuation of her birth control . under abnormal weight gain , her dexamethasone suppression test was normal , 2 out of 3 solid chorisol tests were normal , not consistent with cushing's and therefore , ruling out cushing's . under her hirsutism , her androgen levels were normal . for the acne vulgaris , the epiduo was not covered , so we will try benzoyl peroxide with clindamycin and remove the previous information on the hypothyroidism . we will print out her prescriptions unithyroid should be better priced with the discount card and we will repeat levels of everything before next visit . thanks . | CHIEF COMPLAINT
Hypothyroidism.
Abnormal liver enzymes.
Abnormal weight gain.
Acne vulgaris.
HISTORY OF PRESENT ILLNESS
Christine Hernandez is a 39-year-old female who presents today for evaluation and management of abnormal liver enzymes and hypothyroidism.
When the patient was last seen, her thyroid medicine was changed to Unithroid, but due to the cost of $75, she has not yet started the new medicine and continues taking her previous thyroid medicine. She denies utilizing the coupon that was previously recommended for the Unithroid. Similarly, the patient was prescribed Epiduo for her acne vulgaris, which she did not fill due to the cost of $100. She tried filling both prescriptions at Walmart.
Mrs. Hernandez still presents with abnormal weight gain. She questioned if her oral contraceptive Microgestin, which was discontinued, could have been the cause. Additional symptoms included acne, hirsutism. She is attempting to modify her intake and plans to resume her gym membership in July as she will be on vacation. She inquired about the impact on weight loss of chromium, CLA, and amino acids.
The patient confirmed that she is taking her high dose Vitamin D as prescribed. She does suffer from constipation and she treats with MiraLAX.
She denies previous treatment for her acne vulgaris. She denies ever using clindamycin topical antibiotic. She reports having sensitive skin, developing rashes with various skin products.
PAST HISTORY
Medical
Hypothyroidism.
Acne Vulgaris.
Vitamin D deficiency.
Abnormal weight gain.
Hirsutism.
Constipation.
CURRENT MEDICATIONS
Benzoyl Peroxide.
Clindamycin Gel applied topically.
Vitamin D 2000 IU daily.
Unithroid.
MiraLAX.
ALLERGIES
No known allergies.
RESULTS
Dexamethasone Suppression Test: Normal.
Salivary Cortisol Tests: 2 out of 3 were normal. Not consistent with Cushing’s Syndrome.
Hepatic Function Panel: ALT 128.
Lipid Panel: Total cholesterol 222 mg/dL, HDL 44 mg/dL, LDL 153 mg/dL, non-HDL 178 mg/dL.
FAI: Normal.
ASSESSMENT
• Hypothyroidism.
• Abnormal liver enzymes.
• Abnormal weight gain.
• Acne vulgaris
• Vitamin D deficiency.
• Hirsutism
PLAN
Hypothyroidism
The patient will again attempt to initiate Unithroid. I have printed out the prescription and a discount card, which should result in a reduced price. She will contact my office if she encounters additional issues.
Abnormal liver enzymes
We have seen improvement since the discontinuation of Microgestin. I recommended the spermicide Phexxi for alternative birth control. The patient will also continue working on weight loss, which should additionally improve her liver enzymes.
Abnormal weight gain
Cushing’s Syndrome has been ruled out. I reviewed the weight loss study with the patient, she will call within a month if she is interested in participating. I advised her to follow a low carbohydrate, low cholesterol, abstain from alcohol, and reduce fatty foods diet.
Acne vulgaris
Epiduo was not covered and too expensive. The patient will try benzoyl peroxide and Clindamycin separately to see if the price improves.
Vitamin D deficiency
The patient will complete the high dose vitamin D and then should start vitamin D 2000 IU per day to maintain her levels.
Hirsutism
Her androgen levels were normal.
INSTRUCTIONS
She will repeat all labs prior to her next visit.
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VS010 | virtscribe | [patient] next patient is nicole miller , date of birth is 9/18/1949 . patient was called for a follow-up with me for chronic congestive heart failure with diastolic dysfunction . bnp has been 3000 in march and is about six , was up to 6000 in april . she was increasingly dyspneic . we changed her furosemide and torsemide 20 mg by mouth daily . to note the patient is not currently on potassium supplement , her lisinopril . has also been increased up to 10 mg daily in march also when i saw her in last april she had reported being interested in having her right knee replaced this summer at east metro so it was recommended that we work to control her cardiovascular status before surgery . [doctor] hey miss miller , how're you today ? [patient] i'm doing okay , thank you . [doctor] i asked you to come in today because we want to keep , we want you to have this knee surgery this summer but we want to keep a close eye on you to make sure a week before your surgery , you do n't suddenly go into congestive heart failure and it gets postponed . [patient] yeah , that would not be good . [doctor] i see you're scheduled on the 24th for surgery . [patient] yeah , that's right . [doctor] okay , good . well , it looks like you have lost about three , 3-1/2 pounds since i saw you last in april . some of that might be water weight , but still this is positive . [patient] yeah , i noticed that too . i think the oxybutynin is helping as well . my urgency to use the bathroom is much better . [doctor] well , that's great . [patient] yeah , i'm , i'm pleased about it too . [doctor] do you ever get leg or finger cramps or any , anything like that ? [patient] yeah , i had leg cramps the other day , but i thought it might was maybe just because i was cold as i had my ceiling fan on and fell asleep . i had cramps when i woke up in both legs right here . i drank pickle juice and it went right away . [doctor] well do n't , do n't go crazy with the pill juice because of all the salt in it . [patient] well i know , i only drink about 4 ounces or so . [doctor] okay , good . [patient] it went away , so i did n't drink anymore . i find it works a lot better than trying to put some cream on my leg . [doctor] sure , just , just keep it in moderation . [patient] okay . [doctor] and then are you still on an iron supplement and are you using the bathroom okay ? [patient] yes everything is good . [doctor] good . how is your heartburn doing ? any problems with that ? [patient] no , it did get bad for a while , so i tried to take some prilosec and then stopped that other one . [doctor] okay . [patient] i did that for like gosh , i think it was 2 weeks back in january and have n't had any problems since . [doctor] great . [patient] and after i start taking that i went back to the stomach one , so i'm doing good now . [doctor] okay and you're still due for a colonoscopy , correct ? [patient] yeah , that's right . [doctor] alright , let's , let's review your blood work real quick . i checked your hemoglobin level because you have had some anemia in the past , but that is still doing great . [patient] good , that's a relief to hear . [doctor] your potassium is 3.9 , so it's holding steady on the torsemide . your creatinine was 0.7 , 9.8 , so you're doing well with kidney numbers . your your bun . [patient] maybe a tiny bit elevated at 23 which the number we look for for dehydration , sometimes the kidneys , but it's not terrible . [doctor] so when i look at your numbers as a whole , i think you're tolerating the torsemide okay at the current dose . i also sent out to look at the heart failure number . i sent out to look at your heart failure number . [patient] there is a test called a bnp that i was monitoring and in march it was up to 3000 and then went up to 6000 in april before i made the change and i'm still waiting for those results . okay . [doctor] all in all i think you're doing good on paper though . [patient] what about what's it called a1c , does that show up ? [doctor] i do n't think i ordered it , but i could , your last a1c was 5.5 in march . [patient] already . [doctor] so your blood sugar is a little bit high , it was 169 today but that kinda depends on what you ate and you were n't fasting for the blood check , so i might have to repeat that test for preop , but i do n't think we need to do it today . [patient] alrighty , that sounds good . i checked your magnesium level because sometimes you , you urinate out magnesium and with the water pills , but it was normal at 1.7 and your , your blood pressure is also looking good . okay , great . that all sounds awesome . [doctor] alright , let's take a quick listen . use my general physical exam template and take a couple of deep breaths for me . your lungs sound pretty good to me , so keep doing what you're doing like i said , i think you're doing good overall , but let's just talk about a few things . [patient] alrighty . [doctor] so we often like to keep people with heart problems on magnesium , [patient] and get their levels up to around the two–-ish range . yours is a little bit less than two and we want that two–-ish range because because it can help stabilize the heart muscle so i might recommend putting you on a magnesium supplement . it's to be twice a day , so that's kind of annoying . but i know you're on other medicines twice a day too so i think you'll do fine . yeah that will be okay . great now before surgery , we'll have to get you off your clopidogrel for a week beforehand . yes , okay . i have everything written down on my phone and i have a letter taped the side of my bed to remind me . [doctor] perfect . we will give you a reminder as well . we will also need to complete a preop check within 2 weeks after surgery during the first or second week of june . [patient] okay . i'll put that down . you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekg's we do n't need to do any x-rays of your chest because you had one recently and we do n't need anymore blood work because we did that today . yeah , i do a lot of ekgs . i'm basically a regular , but i'm happy to do one today , no problem . [doctor] lastly once we get your knee surgery we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ? [patient] yeah , i have both . [doctor] okay , so yes , you can get it , your colonoscopy , wherever you'd like . okay , well my husband's insurance may be running out , might we be able to get the procedure done sooner maybe in the next 30 days , is that okay ? [patient] i could put it in right now for for county for the next 30 days and then might be able to get you in within the next few weeks . it should not take it should not make you an eligible for the surgery . in other words , completing the colonoscopy would not delay your surgery . [doctor] okay good . [patient] so let me see , i've been doing one of two things and everyone , and everyone is great , so it depends more on timing and availability of their or for the colonoscopy we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical and they do it at springfield . [doctor] okay that sounds good . [patient] i think either direction they are good technicians of the colon okay , yeah , whatever you can get me in , that works great . [doctor] so i'll call around , now if you get that done and they tell you 10 years , then you'll be good to go . [patient] great , thank you . [doctor] you're welcome . have a great day and let us know if you need anything else , okay . [patient] sounds good . alright assessment and plan , chronic chf , mixed presentation , had a exacerbation of cf chf earlier in the spring , we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about three , 3-1/2 pounds down in weight . breathing is nonlabored , and going to repeat ekg today , but otherwise continue her current regimen . labs checked and creatinine is appropriate . # 2 , preop examination , she is , she is having a , a right knee replacement end of june . also , she would like to have a colonoscopy performed , which we will try to have done at county hospital in the next month prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer . the next one is . [doctor] diabetes . a1c is 5.1 on the last check , so no need for further a1c today . she may need another one prior to her surgery next month though . thanks . | CHIEF COMPLAINT
Follow-up.
HISTORY OF PRESENT ILLNESS
Nicole Miller is a 71-year-old female who presents for follow-up. The patient was called in for a follow up with me for chronic congestive heart failure with diastolic dysfunction. Her BNP had been 3000 in 03/2021, up to 6000 in 04/2021. She was increasingly dyspneic. We had changed her furosemide to torsemide at 20 mg by mouth daily. The patient is not on a potassium supplement currently. Her lisinopril had also been increased up to 10 mg daily in 03/2021.
I last saw her in 04/2021, and she had reported being interested in having her right knee replaced this summer at East Metropolitan Hospital, so it was recommended that we work to control her cardiovascular status prior to surgery. She is currently scheduled to have surgery on 06/24/2021. She plans to discontinue clopidogrel a week before her surgery.
The patient states that she has lost approximately 3 to 3.5 pounds since her last visit in 04/2021. Some of which may be water weight decreasing. She did report experiencing bilateral leg cramps which she treated with consumption of pickle juice, which did resolve the cramps. She thought the cramps were related to her being cold.
She is still taking iron supplementation. She denies any concerns with defecation.
Regarding her prior symptoms of heartburn, she denies any recent gastrointestinal issues. She notes that her heartburn was severe at one point but resolved after trying Prilosec for 2 weeks in 01/2021. She denies any issues with heartburn since that time and has stopped taking Prilosec altogether. She has since transitioned back to her original "stomach medication".
The patient is due for a colonoscopy. She is currently double covered with Medicare and private insurance.
PAST HISTORY
Medical
Chronic Congestive Heart Failure.
Iron deficiency Anemia.
Medications
Prilosec.
FAMILY HISTORY
No family history of colon cancer.
CURRENT MEDICATIONS
Torsemide 20 mg by mouth daily.
Lisinopril 10 mg daily.
RESULTS
Magnesium 1.7, hemoglobin WNL, potassium 3.9, creatinine 0.7, BUN 23.
03/2020 Hgb A1c 5.5.
ASSESSMENT
• Chronic congestive heart failure with mixed presentation.
• Preop examination.
• Diabetes mellitus.
• Colonoscopy
PLAN
Chronic congestive heart failure with mixed presentation.
She had an exacerbation of CHF earlier in the spring. We switched her from furosemide to torsemide and symptomatically, she is doing a lot better. She is about 1.5 kg down in weight. Her breathing is nonlabored. We are going to repeat an EKG today. Otherwise, continue her current regimen. Labs were checked and creatinine is appropriate. Her magnesium is below the preferred 2 at 1.7, with some occurrence of bilateral leg cramping, therefore we will start her on magnesium supplement.
Preop examination.
She is going to be having a right knee replacement at the end of 06/2021. We will schedule a preop check the first week or two of June prior to the surgery. She will discontinue clopidogrel for one week prior to knee replacement surgery; we will provide a reminder to patient of this as well.
Diabetes mellitus.
A1c is 5.5 on last check, so there is no need for a further A1c today. She may need another one prior to her surgery next month.
Colonoscopy.
The patient is overdue for a colonoscopy, which we will try to have done at County Hospital in the next month, prior to a change in her insurance. This is just a screening colonoscopy that she is overdue for. No family history of colon cancer.
The patient understands and agrees with the recommended medical treatment plan.
INSTRUCTIONS
Complete EKG today. Schedule a preop checkup 1st or 2nd week of June. Start magnesium supplement. Call the clinic with any questions or new symptoms.
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VS011 | virtscribe | [doctor] patrick allen , date of birth 7/7/1977 . new patient visit . past medical history includes gerd , anxiety , depression , here for chronic abdominal pain , he had an abdominal ct on 1/23/2020 . impression is a normal ct of the abdomen . hello , are you mr. allen ? [patient] yes , i am . [doctor] hi , my name is dr. edwards , nice to meet you . [patient] nice to meet you . [doctor] welcome to the gi specialty clinic . [patient] thank you . [doctor] did you have any problems finding this ? [patient] no , i've been here with my sister once before . [doctor] good , so how can i help you today ? the referral i have is for abdominal pain and diarrhea . [patient] right so i've had been having this pain right here in my stomach like right around here . [doctor] so in the area of your mid abdomen just below the belly button ? [patient] correct . i've had the pain on and off for about 2 years . i finally went to the er and a a few months ago and they did a ct scan . [doctor] i saw that . [patient] yeah , they said they did n't really see anything on the scan . [doctor] yes , i agree , it looked normal . [patient] and the problem is i'm either constipated or have explosive diarrhea . [doctor] is the pain there all the time ? [patient] it's a nagging feeling and it just depends , sometimes it bothers me , sometimes it does n't . [doctor] has this been the case over the past 2 years as well ? [patient] more recently in the past couple of months at least with the constipation and diarrhea . [doctor] and before that , how were your bowel movements ? [patient] they were normal . [doctor] okay , so any blood in your stool ? [patient] nope . [doctor] do you feel like you have more constipation or diarrhea ? [patient] probably more constipation . [doctor] okay , so when you're constipated , do you not have a bowel movement or is the stool hard ? [patient] i usually do n't go , but when i do , it's hard . [doctor] and how often do you have a bowel movement when you are constipated ? [patient] about 3-4 times a week it's like when i need to go to the bathroom if i can massage it , it feels like it's moving some and i can eventually go . [doctor] okay and when you have a bowel movement , does the pain change ? [patient] yeah . it gets a little better . [doctor] and are you eating and drinking okay , any nausea or vomiting , heartburn or indigestion ? [patient] none of that . [doctor] okay , so tell me about the diarrhea . how often do you get it ? [patient] it kinda just depends on what i eat . i think i have a very sensitive stomach if i eat pasta with a creamy sauce i'm probably gon na have diarrhea . [doctor] okay and does it happen for multiple days in a row or is it just one time ? [patient] it's usually just one time and then it's over . [doctor] and how has your weight been , any fluctuation ? [patient] no , it's been pretty stable , although i could stand to lose about 25 pounds . [doctor] okay , and is there any family history of gi issues that you know of ? [patient] not that i can think of . well , actually my sister does have problems with her stomach too . she has irritable bowel syndrome and that is kind of what i always thought i had even though i have never been diagnosed with it . [doctor] okay and is there any family history of gi cancer or liver disease ? [patient] no . [doctor] have you ever had any surgeries on your abdomen ? [patient] i have never had any surgery . [doctor] okay , so your gallbladder , appendix , all of those are still intact ? [patient] yep . [doctor] and have you ever had a colonoscopy ? [patient] no . i thought that happened when you turned 50 . [doctor] well that's for colon cancer screening , but there are other reasons to have a colonoscopy like unexplained abdominal pain and changes in bowel habits . [patient] okay . [doctor] well , come have a seat here and lay back so i can examine you . [patient] okay . [doctor] i'm gon na start by listening to your belly with my stethoscope . [patient] okay . [doctor] and i hear bowel sounds in all four quadrants . [patient] what does that mean , is everything okay ? [doctor] it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working . [patient] okay , good . [doctor] so now i'm going to push on your upper and lower abdomen , let me know if you have any pain . [patient] it hurts a little when you push right there on the left side near my belly button . [doctor] okay , i do feel stool in your lower colon which would coincide with constipation but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ? [patient] yes . i had a physical about 4 months ago and they i had blood drawn then . [doctor] okay and did your primary care physician say anything about the lab results ? [patient] he said i had some very slightly elevated liver enzymes but we would recheck them in about 6 months . [doctor] and do you remember what enzymes were elevated , alt , ast , alp ? [patient] he said the alt and the ast were elevated . [doctor] and do you take any medications either prescription or over the counter ? [patient] i take crestor and , and olmesartan daily and then tylenol for occasional , occasional pain . [doctor] and how frequently do you take the tylenol ? [patient] hardly ever , maybe once a month . [doctor] and do you consume alcohol ? [patient] yes , but only a couple of beers after working in the yard on saturdays . [doctor] okay and no previous history of heavy alcohol or drug use ? [patient] no . [doctor] and have you had any recent issues with excessive bruising or bleeding ? [patient] nope . [doctor] and how about any issues with your ankles or feet swelling ? [patient] no . [doctor] okay , i'm gon na take a look at your eyes and skin . i do n't see any jaundice . [patient] what would cause that ? [doctor] issues with your liver . let me take a quick listen to your heart and lungs . [patient] okay . [doctor] lungs are clear bilateral . heart sounds are normal . no murmurs , gallops , or rubs noted . [patient] that's good . [doctor] yes , the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly . [patient] what's that ? [doctor] increased stool burden means that there is a lot of stool sitting in your colon . [patient] and that's the constipation , right ? but what about the other thing ? [doctor] the hepatomegaly means the liver is enlarged . [patient] but you said mom was slightly enlarged . [doctor] correct . [patient] so what does that mean ? [doctor] well , let's talk about what we found and then some possible next steps if you're in agreement . [patient] okay . [doctor] so as i said , the hepatomegaly means your liver is enlarged . [patient] could that be why my stomach is hurting and i'm having issues with the constipation and diarrhea ? [doctor] no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat and we can get you started right away on a fiber supplement that should help with that . [patient] so what about my liver , why is it enlarged ? [doctor] well , there are many reasons why people can have an elevated liver enzymes and also an enlarged liver . some possible causes are certain medications that can be toxic to the liver . alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease . [patient] so what do i need to do ? [doctor] well , i think since it's been about 4 months since your blood work was done , we should check your liver enzymes in addition to a few other labs . [patient] okay and then what ? [doctor] we will get those drawn today and then depending upon the results , you may need an ultrasound of your liver . i think we need to talk about your medications too . [patient] which medications ? [doctor] crestor , how long have you been taking that ? [patient] about 18 months . [doctor] okay , well crestor is one of the medications that can cause liver toxicity , so it may be a good idea to discuss other alternatives . [patient] should i talk to my primary care or can you change it ? [doctor] i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol . [patient] okay . i'll call him this afternoon . [doctor] great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that . [patient] okay . when do you think i'll be able to get the ultrasound done ? [doctor] hopefully within the next 2 weeks , you will receive a call from the radiology scheduling this afternoon to get it set up . [patient] okay and then what happens ? [doctor] when i get the results from the tests , i'll contact you and depending upon what we find , we'll come up with our next steps . [patient] and when should i see you again ? [doctor] let's schedule an appointment when you check out to return in 4 weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver . [patient] okay . is there anything else i can do to help with these issues ? [doctor] definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day , in addition to taking the fiber supplement to help with your constipation and be mindful of eating foods that you are sensitive to so you can avoid the bouts of diarrhea . [patient] okay and i will talk to my primary care about my crestor . [doctor] excellent and do you have any other questions for me ? [patient] i do n't think so . [doctor] great . so remember when you check out at the front desk , schedule a follow-up appointment with me for 4 weeks and then go to the lab to get your blood work drawn . [patient] okay , sounds good . [doctor] and expect a call from radiology scheduling about setting up your ultrasound . [patient] alright . thanks dr. edwards . [doctor] thank you mr. allen . | CHIEF COMPLAINT
Abdominal pain and diarrhea.
HISTORY OF PRESENT ILLNESS
Patrick Allen is a 42-year-old male who presents for a new patient visit for chronic abdominal pain, constipation, and diarrhea.
Mr. Allen reports experiencing intermittent mid-abdominal pain for approximately 2 years. The pain is localized just inferior to the umbilicus and he describes it as a “nagging feeling” when it is present. The pain sometimes improves following a bowel movement. Unfortunately, Mr. Allen reports that the pain has been present more often in the past 2 months. In 01/2020, the patient presented to the emergency room due to the pain and underwent a CT scan.
In addition to the abdominal pain, Mr. Allen complains of constipation and episodic severe diarrhea for the past 2 months; however, he estimates that the constipation is more frequent than the diarrhea. When he is constipated, he has a bowel movement 3-4 times a week and the stools are hard. Regarding his diarrhea, he has noticed that it seems to be associated with certain foods. In particular, he notes that pasta with a creamy sauce is likely to prompt an episode of diarrhea. When this occurs, he usually has just 1 bowel movement of diarrhea and then it resolves. The patient states that, prior to 2 months ago, his bowel movements were normal. Mr. Allen notes that massaging his abdomen has sometimes been helpful in producing a bowel movement.
The patient’s last physical was 4 months ago, and he confirms that he did have bloodwork that day. Mr. Allen reports that his primary care provider notified him that his AST and ALT were mildly elevated and advised that they would need to recheck his liver enzymes in 6 months. The patient’s medication list includes Crestor and olmesartan daily and he estimates that he has been taking the Crestor for approximately 18 months. He also takes Tylenol as needed for pain, approximately once a month. The patient states that he drinks 2 beers once a week and denies a history of heavy alcohol or drug use. He also denies excessive bruising or bleeding and any lower extremity edema.
The patient denies blood in his stools, nausea, vomiting, heartburn, and indigestion. He confirms that he is eating and drinking normally, and his weight has been stable. He does acknowledge that he would like to lose 25 pounds, however. He has no family history of gastrointestinal cancer or liver disease; however, his sister has irritable bowel syndrome (IBS). The patient has not had any prior abdominal surgeries and he has never had a colonoscopy.
PHYSICAL EXAM
Respiratory
Lungs clear to auscultation bilaterally.
Cardiovascular
No murmurs, gallops, or rubs.
Abdomen
Normoactive bowel sounds in all 4 quadrants. There is mild left periumbilical tenderness to palpation, mild hepatomegaly, and increased stool burden in colon.
RESULTS
CT of Abdomen, 01/23/2020.
Impression: Normal CT of abdomen.
ASSESSMENT
• Constipation
• Mild hepatomegaly
PLAN
Patrick Allen is a 42-year-old male who presents for a new patient visit for chronic abdominal pain, constipation, and diarrhea. The most likely etiology of his abdominal pain is constipation given his history, exam with increased stool burden, and normal abdominal CT. Mild hepatomegaly was also noted on exam today and the patient reportedly had elevated liver enzymes on labs with his primary care provider 4 months ago. The patient is currently on Crestor which may be contributing to his elevated liver enzymes. We discussed findings, diagnosis, and next steps at length.
Constipation
• Start daily fiber supplement and increase water consumption to at least 48 ounces daily to help with bowel regularity.
• Avoid trigger foods that may cause episodes of diarrhea.
Mild Hepatomegaly
• Repeat liver enzyme labs today.
• Schedule a liver ultrasound pending lab results.
• Encouraged to cease alcohol consumption.
• Patient to contact his PCP to discuss alternative medications.
INSTRUCTIONS
Return to clinic in 4 weeks.
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VS016 | virtscribe | [doctor] eugene walker date of birth 4/14/1960 he is a 61-year-old male who presents today for routine follow-up of his chronic medical conditions of note the patient underwent an aortic valve replacement and a sending aortic aneurysm repair on 1/22/2013 regarding his blood work from 4/10/2021 the patient's alkaline phosphatase phosphatase is me was elevated to 156 his lipid panel showed elevated total cholesterol of 247 hdl of 66 ldl of 166 and triglycerides at 74 the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . good morning mr. walker how are you doing i mean has been a crazy year i'm doing fine for the most part but there are a few things on cover today sure drawn ahead . [patient] well i'm having more fatigue , but i do n't know if it's age or if it's just you know drained at the end of the day , but i still ride my bike . i ca n't go as fast as i used to , i'm still riding and you know after a long bike ride , i'll sit down and then boom , i'm out , you know . [doctor] yeah , what's a long bike ride do you ? [patient] 20 to 30 miles . [doctor] 20 to 30 miles , on a road bike ? [patient] yeah , road bike . i think it's a time thing . if i have more time , i would try to do my 40 miles , but i have n't done that . obviously we are too early in the season , so my typical ride is like 2030 . and years back , i could do 40 on a good day . i could still do 20 , but you know i'm tired and have to take a break when i get home . [doctor] yeah , i understand . [patient] and tyler is my buddy . he is always nice and weights for me , but i used to be able to beat him , but now he waits for me all the time , he is older than me and it it kills me . [doctor] yeah , i can imagine that would help sent me to . [patient] the last time you know you found a heart thing then , just making sure that the valve is holding out , you know . [doctor] right , so when was your last stress test ? [patient] it was september 9 , 2019 because i'm 8 years out from surgery and back then they said . you know it's going to last 8 years and i'm at that year , so i just wan na make sure . i asked dr. lewis for an echocardiogram to see how i'm doing . [doctor] yeah . [patient] but it's not like nothing has changed drastically since i saw you . [doctor] okay , good . do you still go down to hopkins at all ? [patient] no , not at all . i just get follow-ups intermittently here , going there is just is too much stress . [doctor] okay . [patient] 01 more thing , i want to make sure i do n't forget . my wife and friends tell me that when i walk , i purse my lips when i'm breathing , other doctors have said did you notice your pursed lips breathing . i do n't know if that's a bad habit or what . [doctor] okay . is there any wheezing associated with that ? [patient] no , no reason . [doctor] and you're able to bike 30 miles and mostly keep up with your friend's tyler , correct ? [patient] yeah . the only other thing i wan na mention is it's not like i do routine testicular exams . but i know i have this little nodule on my right testicle . [doctor] on the testicle or the epididymis ? [patient] epididymis . i really do n't know . i'm not super concerned or read a little online , just wanted to ask you . [doctor] and did you have a vasectomy ? [patient] no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those are the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know . i just know you would ask those questions . [doctor] what time are you going to sleep and about how many hours do you sleep at night ? [patient] it varies usually i get 6 to 7 hours of sleep , i get out of bed some days to be at work by seven lecture and i try to work out in the morning . i i do n't , i'm not , i'm not really successful and now what i do is i , i do make reservations twice a week for 545 swim in the morning . [doctor] okay , so you're getting 6 to 7 hours of sleep and has your wife ever mentioned if you snore or stop breathing at any time ? [patient] i believe i snore a little bit , but she has never said anything about me not breathing . [doctor] okay . so you're currently taking vitamin d3 around 5000 units on sundays and 2000 or 50,000 units on sundays excuse me and 2000 on the other 6 days and then clindamycin prior to dental procedures correct . [patient] yeah , that's right . [doctor] have you had a covid-19 shot yet ? [patient] i've received both . my first dose on january 15 , 2021 and my second on february 5 , 2021 . [doctor] good . if you hop up here on the table , we're just gon na do a physical exam . well mr. walker overall you're doing well i'm going to order an echocardiogram and a stress test i also recommend that you follow-up with cardiology i think dr. vincent sanchez would be a great fit for you . [patient] alright . [doctor] also your recent labs showed an elevated alkaline phosphatase level at 156 now this could be related to your liver but most likely related to your bone health we are going to check a few labs today . [patient] you're going to have them done today ? [doctor] yes sir and we will send the results through your patient portal unless something is way off and will give you a call sounds good now as far as your breathing i observe the pursed lip breathing and your exhalation is low i think you should do a pulmonary function test to further evaluate and i would evaluate as well now the nodule in your right testicle should be evaluated by urology and we will place that referral today also . [patient] sounds like you're gon na be busy getting this all checked out . [doctor] yes sir now you're due for your mmr and i'm recommending you get the shingles vaccine as well . you have completed your covid-19 so that's good . now i'm gon na have have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies . do you have any other questions for me ? [patient] no , document . i think you covered it all . [doctor] great okay the nurse will be back in a minute to give you mmr today and the front desk will line up the time to do the shingles vaccine next month thanks doc have a great day alright , use my general physical exam template . for respiratory , notate pursed lip breathing , low exhalation phase , clear to auscultation , no wheezing . genitalia notiate right testicle with 2 to 3 mm palpable nodule . does not feel as if it will does not feel as if with the epididymis or varicocele left testicle normal no hernia all other portions of the physical exam are normal default assessment history of aortic aneurysm repair the patient underwent an aortic valve replacement and a sending aortic aneurysm repair on 1/20/2013 he is doing well overall and currently asymptomatic he is currently not seen by cardiology routinely suggested following up and suggested vincent sanchez at this physician . we will perform an echocardiogram/stress test elevated alkaline phosphatase level most recent cmp showed elevation at 156 this could be related to his liver but most likely related to his bone health i have ordered an alkaline phosphatase and again a gt lung field abnormal finding on x eliciting on examination the patient has been noted to purse his lips while breathing he was found himself he has found himself feeling more fatigued at the end of the day he does bicycle around 20 to 30 miles at a time his excellent exhalation phase is low on exam and i have ordered pfts today to further for further evaluation the right testicular nodule about 2 to 3 mm noted on the exam . there is no hernia palpable and i have suggested reaching out to urology for possible ultrasound preventative health most recent blood work was reviewed with no significant abnormalities abnormalities other than the cmp we will perform nmr titer today i have suggested the shingles vaccine he is fully vaccinated against covid-19 patient will return for follow-up in 1 year for a wellness visit , sooner if needed . he is to call with any questions or concerns . | CHIEF COMPLAINT
Routine follow up of chronic medical conditions.
HISTORY OF PRESENT ILLNESS
Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions.
Today, the patient reports feeling more fatigued as of late. He notes that he usually rides his bike for about 20 to 30 miles and by the end of his ride he is tired enough that he will immediately fall asleep. The patient adds that he can fall asleep easily and gets about 6 or 7 hours of sleep per night. He believes he snores a bit but denies any signs of apnea.
Of note, the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 01/22/2013. As he is now 8 years post-op, he has requested an echocardiogram from Dr. Lewis to review how he is doing currently. His last stress test was performed on 09/09/2019.
Mr. Walker reports that his wife and friends have told him that he has pursed lips when he walks. This has also been noticed by his other providers. He denies any wheezing.
Furthermore, the patient has noticed a 2 to 3 mm nodule in his right testicle, possibly with the epididymis but he is unsure. He has not had a vasectomy.
His current medication list only consists of clindamycin prior to dental procedures and vitamin D3 (50,000 IU on Sundays and 2000 IU the other 6 days).
From a preventative standpoint, the patient is due for the shingles vaccine and an MMR titer. He is fully vaccinated for COVID-19 with his first dose on 01/15/2021 and his second dose on 02/05/2021.
PHYSICAL EXAM
Respiratory
Pursed lip breathing noted. The exhalation phase is low. Lungs are clear to auscultation, no wheezing.
Genitourinary
No hernia noted. Left testicle normal.
RESULTS
Regarding his blood work from 04/10/2021, the patient's alkaline phosphatase was elevated at 156. His lipid panel showed elevated total cholesterol of 247, HDL 66, LDL 166, and triglycerides 74. The patient's TSH was normal at 2.68. His CBC was unremarkable. His most recent vitamin D level was at the high end of normal at 94.
ASSESSMENT
• History of aortic aneurysm repair.
• Elevated alkaline phosphate level.
• Lung field abnormal finding on examination.
• Right testicular nodule.
• Preventative health.
PLAN
Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions.
History of aortic aneurysm repair.
- Overall, he is doing well and currently asymptomatic.
- Currently he is not seen by cardiology routinely and I have suggested he follow up with Dr. Tyler Sanchez.
- Ordered echocardiogram and stress test.
Elevated alkaline phosphate level.
- Most recent CMP showed elevation at 156 IU/L.
- This could be related to his liver but most likely related to his bone health.
- Ordered an alkaline phosphatase and gamma GT.
Lung field abnormal finding on examination.
- The patient has been noted to purse his lips while breathing.
- He had found himself feeling more fatigued at the end of the day.
- He does cycle 20 to 30 miles at a time.
- His exhalation phase was low on exam.
- Ordered pulmonary function testing for further evaluation.
Right testicular nodule.
- 2 to 3 mm nodule noted on exam. There is no palpable hernia.
- Referral placed to urology for possible ultrasound.
Preventative health.
- Most recent blood work reviewed with no significant abnormalities.
- He is fully vaccinated against COVID-19.
- Recommend shingles vaccine next month.
- MMR titer performed today.
INSTRUCTIONS
- Return in 1 year for routine wellness visit, sooner if needed.
- Call with any questions or concerns.
|
VS026 | virtscribe | [doctor] donna torres , date of birth 8/1/1980 . hi donna , how are you ? [patient] i'm good , how about you ? [doctor] i'm doing well , thank you and so i saw that doctor brown put you on buspar . have you been on that before ? [patient] no , that's new . [doctor] okay . how is it working for you ? [patient] my anxiety's going good now . thankfully , i'm serious . it was brutal in november and december . finally , i was like i can not do this . i have no idea why it happened . dr. ward did put me on singulair , she did say we need to be careful because singulair can cause anxiety , so i'm not sure if that was the issue or what . [doctor] hmmm okay . [patient] and i would start usually during the day at work . [doctor] i see . [patient] i mean i'm fine now . [doctor] well , that's good that things have settled . i do wonder if some of what you were dealing with is hormonal and that's why i was asking because you were on the progesterone and i feel like you were having some irritability back then too . [patient] i did . [doctor] and that was before we started the progesterone . [patient] yes . [doctor] so i know we started for regulating your periods , but perhaps it helped with this also . [patient] yeah , and before in november and december , i noticed that the week before my period , my anxiety would go through the roof , which then i knew my period was coming , then it turned into my anxiety spiking , just at random times . [doctor] hmmm okay . [patient] and it seemed like it was for no reason . [doctor] but november and december you were on the progesterone at that time . [patient] yes . [doctor] alright , so not really a link there , alright . [patient] yeah , i do n't know . [doctor] yeah , i do n't know either . sometimes with the aging process , that can happen too . [patient] i figured maybe that's what it was . [doctor] and we did go through the go live in november and december so that can be pretty stressful also . [patient] yeah and that worked and that's when i first started to leave the process of delivering the results to patients with covid in the beginning of the whole pandemic , patients would have to wait 9 days before they get their results and then we open the evaluation centers and the covid clinic , so i think it just took a toll on me . [doctor] yeah , i can absolutely see that . [patient] yeah and then i was feeling selfish because i was n't even on the front lines i mean i was supporting people sure but i was n't in the icu so i felt selfish and guilty i mean hands down , the physicians and nurses were in the thick of it and there i was having anxiety and it's not ridiculous . [doctor] well , honestly you feel how you feel and what you were doing was n't easy as well , so but let's see , i need to just put this dax back to work . alright . so no other issues whatsoever ? [patient] no . [doctor] have you lost weight ? [patient] no , when i stopped taking the camilla birth control , my hunger level was at a new high . i mean i was eating constantly . i felt like what was going on . [doctor] alright . [patient] and now i am feeling better . [doctor] okay . that's good . and your mask face though , it does look thinner . [patient] well , in the past 6 months , i have lost some weight . [doctor] okay , good . anything else going on ? [patient] no . [doctor] alright . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative , negative . have you ever had an abnormal pap ? [patient] not with you , but i did around 2009 and then i had to be seen every 6 months for a while and then i had a normal pap . [doctor] alright , well let's just repeat it then . [patient] yeah , that's fine with me to be safe . [doctor] okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under and the potential for getting covid , or the vaccine , i have actually seen some an increase in abnormal paps in people who have been fine for a while , so that's why i figure let's just check . [patient] okay . and i fight the vaccine fight every day at home because my husband is n't ready to get it , same with my daughter . she shares the same worries as her dad and how will it impact her when she gets older . [doctor] have you had the vaccine ? [patient] yes , i have and so has my son , he has had his first already . [doctor] okay , well , you know you can only do what you can do . [patient] yeah , i agree . [doctor] alright , well , let's complete your exam . [patient] alright . [doctor] so let's take a deep breath , and again alright you can breathe normally . [patient] alright and take one more deep breath , [doctor] okay , now i'm gon na touch your neck . go ahead and swallow . perfect and just place your hand above your head okay , i do feel some little bumps . [patient] yeah , but they are not as big as they were . [doctor] mm-hmm . okay , in this breast , it does feel a little bit denseer . does it hurt at all ? [patient] it does where your left hand just was . [doctor] okay , right here ? [patient] yeah , down here , but whenever i breast-fed , it was always sore there too , i had a clog and something else , the lumps do feel smaller , but they are still there unfortunately . [doctor] yeah , they are , well now i do n't know because if it was the progesterone , they would have gone away . [patient] yeah . [doctor] alright , well just let your knees just relax and open . how's the itching or discomfort ? are you still using the cream ? [patient] yes and i actually need to get that refilled for the first time ever . [doctor] okay . [patient] but yeah , i use it once a week and it does help . [doctor] okay , great . alright , looks good . [patient] good . [doctor] you can go ahead and sit up . [patient] thank you . [doctor] alright , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles and you've had two cycles so far . so i think let's just keep monitoring them for now . [patient] okay . and what could that mean ? [doctor] well , so just like people have an increased risk of breast cancer , there is also an increased risk for breast issues . you know what i mean ? so for example , cyst . and lumps and fibroadenomas . those are all benign things . they are annoying and requires some work-up , but they are all benign . [patient] and i'm , i'm just worried because i'm almost full . 40 and my mom was almost 45 when she was diagnosed with breast cancer , so i mean i know there is nothing i can do about it but it's just i feel like we had it under control and now it is n't . [doctor] well i would n't say that . i mean i feel like we're at a point where we have a good cadence for you having surveillance on things and i think you are more aware of your breasts than ever before and things actually have n't changed . [patient] yeah . [doctor] so those are all good things . [patient] okay . [doctor] because if it was cancer , it would actually we would see some change . [patient] it would , okay . thank you for explaining that . [doctor] yeah . so i know it's annoying and distressing . but i think that's where we're at . it's annoying that you have the breast issue and it's annoying that we have to follow them . [patient] yeah , i agree there . [doctor] but the only extra that i could potentially do is we could get a breast specialist on the team and have you start to follow with them and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam in the office to check out , check it out on their own . they also have a lot more experience and more willingness to sometimes perform procedures earlier if they think it needs if they think it needs to be done . and i think they tend to be much quicker than you know like radiology is to biopsy it . [patient] okay . i'll do whatever you think i should . [doctor] alright . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule . [patient] okay , i think that sounds great . [doctor] alright , i do too . alright , well any questions or anything else we can discuss today ? [patient] no , i think i'm all set . [doctor] alright , good . alright , well have a good rest of your day and just give us a call if you need anything else . [patient] alright , thank you . you have a good day too . [doctor] alright . | CHIEF COMPLAINT
Follow-up bilateral breast cysts.
HISTORY OF PRESENT ILLNESS
Donna Torres is a 40-year-old female who presents for follow-up surveillance of bilateral breast cysts.
The patient reports continual presence of “lumps” in bilateral breasts with some soreness. She is being seen today for surveillance of the cysts. The patient is taking progesterone, which was initially prescribed to support normalization of menstruation, which was effective. She is also still using vaginal cream one time per week which has improved symptoms of itching and discomfort.
Her last pap smear was in 2019, with negative/negative results. She did have an abnormal pap smear in 2009, which resulted in repeat pap smears per 6 months until her results normalized.
Mrs. Torres experienced increased anxiety in 11/2021 and 12/2021, stating “it was brutal” and felt she could not manage her symptoms and sought treatment. Dr. Brown started the patient on Buspar, which has successfully controlled her anxiety. The patient relates her anxiety to work related stress and possibly aging. Her work involves supporting Covid evaluation centers and clinics. She confirms receiving both Covid vaccinations. Initially, she was experiencing spikes in anxiety prior to menstruation, but her anxiety then became more random with an unclear cause. To note, the patient was started on Singulair, which the patient was told could also cause anxiety.
The patient discontinued Camila birth control, which did result in a significant increase in appetite. This has resolved and she reports she has lost weight in the past 6 months.
Gynecologic History
Last pap smear: 2019.
History of abnormal pap smear: 2009.
PAST HISTORY
Medical
Bilateral breast cysts.
Anxiety.
SOCIAL HISTORY
Employed in healthcare, supports Covid evaluation centers and clinics.
FAMILY HISTORY
Mother, deceased age 45, from complications of breast cancer.
CURRENT MEDICATIONS
Buspar.
Singulair.
PHYSICAL EXAM
Genitourinary
Breast: Breast density.
ASSESSMENT
• Follow-up bilateral breast cysts.
• Pap smear.
PLAN
Follow-up bilateral breast cysts
Physical exam indicated stable breast density bilaterally. The patient is being seen regularly for monitoring. The plan is to continue close monitoring and the patient will be referred to breast specialist for additional review. The patient agreed to this plan.
Pap smear
Exam was normal. No additional treatment needed at this time.
INSTRUCTIONS
Schedule appointment with breast specialist. Call clinic with any additional concerns. |
VS027 | virtscribe | [doctor] sophia brown , date of birth 3/17/1946 . this is a new patient visit . she is here to establish care for history of dcis . we'll go over the history with the patient . hello miss brown . [patient] hi , yes , that's me . [doctor] wonderful . i'm dr. stewart , it's lovely to meet you . you as well . so you've come to see me today because you had a right breast lumpectomy last year , is that right ? [patient] yes on january 20 , 2020 . [doctor] okay and how you've been since then ? any problems or concerns ? no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since . perfect . i want to back up and go over your history , so i can make sure everything in your chart is correct and i do n't miss anything . so i will tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing , sound good ? [patient] sounds good . [doctor] great so i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram or was it done because you felt a lump ? it was just a normal one , you were supposed to get every so often . i see and then it looks like you had an ultrasound of your right breast on november 3 , 2019 which revealed a mass at the 2 o'clock position 11 cm from the nipple in the retroareolar region . the report states the mass was . [patient] 0.4 x 2 x 3 cm . [doctor] yes , that sounds right , hard to remember now though . [patient] yeah , definitely . [doctor] based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5 , 2019 . pathology results during that biopsy came back as grade 2 , er positive , pr positive dcis , [patient] or ductal carcinoma in situ . [doctor] yes unfortunately . i know scary stuff but you had a lumpectomy on january 20 , 2020 which removed the 8 mm tumor and margins were negative . [patient] the pathology confirmed dcis looks like they also removed five lymph nodes , which thankfully were negative for malignancy . that's great . [doctor] yeah , i was definitely very relieved . and your last mammogram was in january 2021 and that was normal . [patient] yeah . [doctor] okay . so i feel like i have a good grasp of what's been going on with you now and you're here today to establish . [patient] care with me so i can continue to follow you and make sure you're doing well , right ? [doctor] yes , fingers crossed . [patient] definitely . we'll keep a close eye on you and take good care of you . [doctor] okay , sounds good . i have a few more questions for you . when was your last colonoscopy ? i had one in 2018 and if i remember correctly , i had one polyp and that was removed and it was n't cancerous . [patient] okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular angioma okay and when was your last menstrual period ? [doctor] gosh , it was probably around 30 years ago . [patient] okay . do you have children ? [doctor] i do , i have five . [patient] big family then , that's nice . [doctor] yes and they are all having kids in their own now , so it's getting even bigger . [patient] i bet , sounds like fun . [doctor] it is . did you have any other pregnancies that were miscarriages or terminations ? [patient] believe i did not . [doctor] okay , so for the record that's g5 , p5 . and now that you're postmenopausal , are you currently or have you ever been on hormone replacement therapy ? [patient] my primary care doctor gave me the option years ago , but i decided against it . [doctor] okay . and on your review of systems form , you indicated that you've not had any recent weight loss , or gain , headaches , bone pain , urinary symptoms , or blood in the stools , but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those . okay . so i've seen doctors for all of those . they said excuse me , the back and knee pain are age related and the cholesterol is a fairly new diagnosis . but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication . okay and your primary care doctor is following you for that right ? [patient] that's correct . [doctor] okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit , is that alright ? [patient] yes and that's all . [doctor] okay . so for your medical history , it's high cholesterol and stage 0 , er , pr positive , invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ? [patient] i did have my tubes tied after my last baby , but that's all . [doctor] okay and how about family history ? [patient] my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it . [doctor] alright . any family history of breast cancer ? [patient] none . [doctor] did any of your children have medical issues or siblings with medical problems ? i do not have any siblings and thankfully my children are all healthy . wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ? [patient] no drugs , i do drink socially but never more than that . [doctor] and i used to smoke but really everybody did back then and i probably quit about 30 years ago . [patient] excellent . i have that you're allergic to penicillin . any other allergies ? [doctor] no , just penicillin . okay , i think that covers it . hop up here and let me take a look at you . okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast , which may be radiation , skin changes . [patient] in the result section note that her ecog performance status today is zero . do you have , did you have radiation after the lumpectomy ? [doctor] i did . we also talked about endocrine therapy , but i decided against that . okay . so your exam looks good . no masses , just some skin changes from that radiation . now let's go over the plan for you . [patient] okay , sounds good . [doctor] as you know you had dcis which will list in my note is stage 0 er/pr positive invasive ductal carcinoma of the right breast . you're status post lumpectomy with removal of five lymph nodes that were benign . you also had radiation therapy , but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy . [patient] and your mammogram in january 2021 was also negative for recurrence of malignancy . so based on all of that , we can just continue to observe you . [doctor] okay , that sounds great and when do i come back in to see you ? in a year , but you should have another mammogram in april 2022 before you come back to see me . [patient] okay . i can do that . [doctor] wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ? [patient] i do n't think so . [doctor] okay , great . my nurse will be in shortly to discharge you . take care . you as well . | CHIEF COMPLAINT
History of right ductal carcinoma in situ (DCIS).
HISTORY OF PRESENT ILLNESS
Sophia Brown is a 75 y.o. female who presents today for a new patient evaluation due to her history of right DCIS. She is doing well but wishes to establish care today for continued monitoring.
The patient underwent a screening mammogram in 10/2019 and was found to have a calcification in the right breast. She then had a right breast ultrasound on 11/03/2019 which revealed a mass at the 2 o’clock position, 11 cm from the nipple, in the retroareolar region. The report states the mass was 0.4 by 2.0 by 3.0 centimeters. She subsequently had an ultrasound-guided core needle biopsy on 12/05/2019 and pathology results revealed grade 2 ER-positive, PR-positive DCIS. The patient then had a lumpectomy with lymphadenectomy performed on 01/20/2020. The tumor was 8 mm with negative margins and the 5 lymph nodes removed were all benign. Pathology from the tumor confirmed DCIS. Her lumpectomy was followed by adjuvant radiation therapy. Endocrine therapy was also offered but the patient declined. She has since had a mammogram in 01/2021 which was normal. The patient also reports that she performs self-breast exams regularly at home.
Mrs. Brown is a G5P5 female and estimates that her last menstrual period was approximately 30 years ago. She is not currently and has never been on hormone replacement therapy.
The patient’s last colonoscopy was done in 2018. She had a sigmoid polypectomy at that time and pathology showed a tubular adenoma.
Her cholesterol was recently noted to be elevated and the patient reports that she is exercising and reducing fatty food intake accordingly. This is being followed by her primary care provider.
PAST HISTORY
Medical
Hypercholesterolemia.
Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast, status post lumpectomy and adjuvant radiation therapy.
Surgical
Right lumpectomy, lymphadenectomy x5, 01/20/2020.
Bilateral tubal ligation.
SOCIAL HISTORY
Alcohol: Socially. No history of heavier consumption.
Illicit drug use: Never.
Tobacco: Former smoker. Quit approximately 30 years ago.
Patient has 5 children and multiple grandchildren.
FAMILY HISTORY
Mother: Non-Hodgkin’s lymphoma.
Father: Prostate cancer, heart disease.
Her children are healthy. She has no siblings. Denies family history of breast cancer.
CURRENT MEDICATIONS
Co-Q 10.
Vitamin D.
Vitamin C.
Fish oil.
Elderberry fruit.
ALLERGIES
Penicillin.
REVIEW OF SYSTEMS
Negative for weight loss, weight gain, headaches, bone pain, urinary symptoms, blood in the stools.
Positive for back pain, joint pain, high cholesterol. Patient has sought care for these complaints. She reports that she was told the back pain and joint pain (knee) are age-related. She is being followed for the high cholesterol by her primary care provider.
PHYSICAL EXAM
The ECOG performance status today is grade 0.
Breast: There are no palpable masses; however, there is some skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes.
ASSESSMENT
Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast.
The patient is status post lumpectomy with removal of 5 lymph nodes which were benign. She also underwent adjuvant radiation therapy but declined endocrine therapy. Today’s clinical examination shows no evidence of recurrent disease or other malignancy. She also had a negative mammogram in 01/2021.
PLAN
1. We will continue to observe the patient.
2. She is due for a mammogram in 04/2022.
3. She should follow up with me in 1 year after the mammogram. |
VS028 | virtscribe | [doctor] next patient is sophia jackson , mrnr 472348 . she is a 57-year-old female who is here for a surgical consult . [patient] her dermatologist referred her . she biopsied a 0.7 mm lesion which was located on the right inferior back . pathology came back as melanoma . [doctor] mrs. jackson , it's good to meet you . [patient] likewise , wish you were under better circumstances . [doctor] yeah , i heard your dermatologist sent you to because she found the melanoma . [patient] yes , that's what the biopsy said . [doctor] okay and when did you first notice the spot ? [patient] my mom noticed it when i was visiting her last month . [doctor] i see and so you went to the dermatologist on april 10 to get it checked out , right ? [patient] yes , i wanted to be extra cautious because skin cancer does run in my family . [doctor] well i'm really glad you took a serious and got it checked . who in your family has had skin cancer and do you know if it was melanoma or was it basal cell or squamous cell ? [patient] my mom and her sister i think they both had melanoma . [doctor] okay . do you have any other types of cancer in the family like breast or ovarian ? [patient] my grandfather had pancreatic cancer . [doctor] okay and what about your mom or dad's father ? [patient] mother's . [doctor] okay and have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ? [patient] no , this was the first time i've been to a dermatologist but my primary care doctor looks over all of my moles every year . my physical and has n't said he is concerned about any of them before . [doctor] good , good . let's go over your medical history here in your chart . i have that you are not taking any medications and do n't have any health problems listed , but that you are allergic to augmentin , is that right ? [patient] yes , that's correct . [doctor] okay and for social history , can you tell me what you do for work ? [patient] i own an auto repair shop . okay and have you ever been a smoker ? yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying . [doctor] i'm glad you're trying to quit . what about your surgical history ? have you had any surgeries ? [patient] i had gallbladder and appendix . [doctor] okay , great . we can get your chart up to date now , thank you . and other than the melanoma , how has your health been ? any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ? [patient] no , i've been feeling great . [doctor] good . well , let me take a look at your back here where they did the biopsy if you do n't mind . [patient] sure . [doctor] okay . i'm gon na describe it in medical jargon , what i'm seeing here so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ? [patient] okay , that's fine . [doctor] alright , so on the right inferior back , there is a 1 cm shave biopsy site including all of the dermis with no residual pigmentation there is no intrinsic or satellite lesions . no other suspicious moles . no axillary , cervical or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin but it's nontender . otherwise normal exam . [patient] okay , you can sit up . so what i was saying there is that i see your biopsy site , but i do n't see any other skin lumps or bumps that look suspicious . [doctor] i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing . and you know make sure it's something we need to worry about the reason we are being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further . [patient] okay . i should have worried too much then . [doctor] no , i have a low suspicion that it will show anything . [patient] okay , good . [doctor] so assuming that the ultrasound is normal . the treatment for your melanoma is to cut out the area where the lesion was . with lesions that are 0.7 mm or less and that's what we recommend and yours was exactly 0.7 mm . if it were any bigger , we would have had to do a more complex surgery , but what i recommend for you is what we call a wide local incision , excuse me , excision meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision . [patient] okay , that is fine with me . i ca n't see back there anyways . [doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it as it heals . but since we're we are n't doing the more complex surgery , i actually do n't need to see you back unless you wan na check in with me or have any problems , however , it is very important that you continue to follow up with your dermatologist regularly , so she can monitor you . your dermatologist will check if this one does n't come back , but she will also check for other lesions that look suspicious . unfortunately since you had one melanoma , you are at a higher risk of developing another one somewhere else . [patient] yeah , she did say she wants to see me back . [doctor] good and i'm sure she has already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight . [patient] yeah , she definitely went over that several times with me . [doctor] good . other than that , i think that's all for me . we'll get you set up for the ultrasound and the procedure . do you have any questions for me ? [patient] no , i ca n't think of any at this time . [doctor] okay . my nurse will be in to get you scheduled . so sit tight . it was very good to meet you . [patient] thank you . nice to meet you as well . [doctor] please add the following pathology to results a pathology , shave of right inferior back , malignant melanoma , invasive superficial spreading , histology , superficial spreading . clark level iv , breslow thickness 0.7 mm , radial growth phase present , vertical growth phase not identified , mitotic features less than 1 mm² , ulceration not identified , regression not identified , [patient] lymphatic invasion not identified . perineural invasion not identified , microscopic satellitosis not identified , infiltrating lymphocytes , breast , [doctor] melanocytic nevus not identified , predominant cytology , epithelioid , peripheral margin positive , deep margin negative , stage i . also note that i reviewed the dermatologist photo of the lesion , which showed an asymmetric black and brown nevus with central asmelanotic component and a regular border . for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . [patient] i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a 1 to 2 cm margin . primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up according to the national comprehensive cancer network guidelines was reviewed . we also reviewed the principles of sun avoidance , skin self-examination and the abcde's of mole surveillance . after discussing the procedure , risk and expected outcomes and possible complications , questions were answered and the patient expressed understanding and did choose to proceed . | CHIEF COMPLAINT
Melanoma.
HISTORY OF PRESENT ILLNESS
Sophia Jackson is a very pleasant 57-year-old female who presents for a surgical consult for melanoma of the right inferior back. She was referred by her dermatologist who biopsied the 0.7 mm lesion on 04/10 and diagnosed the melanoma. The lesion was initially noticed by the patient’s mother when she was visiting her last month. Mrs. Jackson denies a personal history of atypical nevi and reports that she has annual mole checks by her primary care provider at her physicals. She has never seen a dermatologist prior to last month. There is a family history of melanoma in her mother and maternal aunt. The patient reports that she has been in her usual state of health with no unintentional weight changes, headaches, fatigue, nausea, vomiting, or vision changes.
PAST HISTORY
Medical
None reported.
Surgical
Cholecystectomy.
Appendectomy.
SOCIAL HISTORY
Patient owns an auto repair shop.
Current smoker since teens. Actively trying to quit.
FAMILY HISTORY
Mother: melanoma.
Maternal aunt: melanoma.
Maternal grandfather: pancreatic cancer.
No family history of breast or ovarian cancers.
MEDICATIONS
None.
ALLERGIES
Augmentin.
PHYSICAL EXAM
Hematologic/lymphatics: No axillary, cervical, or supraclavicular lymphadenopathy. There is a soft lymph node in the right groin. Nontender.
Skin: On the right inferior back there is a 1 cm shave biopsy site including all of the dermis with no residual pigmentation. There’s no intrinsic or satellite lesions. No other suspicious moles.
RESULTS
Pathology Report.
Pathology: Shave biopsy of right inferior back malignant melanoma, invasive, superficial spreading.
Histology: Superficial spreading.
Clark level: 4.
Breslow thickness: 0.7 mm.
Radial growth phase: present.
Vertical growth phase: not identified.
Mitotic figures: less than 1 mm2.
Ulceration: not identified.
Regression: not identified.
Lymphatic invasion: not identified.
Perineural invasion: not identified.
Microscopic satellitosis: not identified.
Infiltrating lymphocytes: breast.
Melanocytic nevus: not identified.
Predominant cytology: epithelioid.
Peripheral margin: positive.
Deep margin: Negative.
Stage: 1.
I reviewed the dermatologist’s photo of the lesion which showed an asymmetric black and brown nevus with central amelanotic component and irregular border.
ASSESSMENT AND PLAN
The patient presents today with newly diagnosed melanoma. The biopsy revealed an intermediate thickness melanoma. On examination today, there is a right inguinal lymph node with slightly atypical consistency. I recommended an ultrasound to rule out metastatic disease. If the ultrasound is normal, the patient is a candidate for a wide local excision with a 1-2 cm margin. Primary closure should be possible, but skin graft closure may be needed. The relationship between tumor histology and prognosis and treatment was carefully reviewed. The need for follow up according to the National Comprehensive Cancer Network (NCCN) guidelines was reviewed. We also reviewed the principles of sun avoidance, skin self-examination, and the ABCDE’s of mole surveillance. After discussing the procedure, risks, expected outcomes and possible complications, questions were answered, and the patient expressed understanding and did choose to proceed. |
VS029 | virtscribe | [doctor] this is philip gutierrez date of birth 1/12/1971 . he is a 50-year-old male here for a second opinion regarding the index finger on the right hand . [patient] he had a hyperextension injury of that index finger during a motor vehicle accident in march of this year . he was offered an injection of the a1 pulley region , but did not want any steroid because of the reaction to dexamethasone , which causes his heart to race . [doctor] he was scheduled to see dr. alice davis , which it does n't appear he did . he had an mri of that finger because there was concern about a capsular strain plus or minus rupture of fds tendon end . [patient] he has been seen at point may orthopedics largely by the physical therapy staff and a pr pa at that institution . at that practice , an mri was obtained on 4/24/2021 . [doctor] which showed just focal soft tissue swelling over the right index mcp joint partial thickness tear of the right fds and fluid consistent with tenosynovitis around the fdp and fds tendons . radial and ulnar collateral ligaments of the index mcp joint were intact as the mcp joint capsule . extensor tendons also deemed intact . his x-rays four views of the right hand today show no bony abnormalities , joint congruency throughout all lesser digits on the right hand . no soft tissue shadows of concern . no arthritis . hi , how are you mr . gutierrez ? i'm good how about you ? [patient] well how can i help you today ? so i was a passenger in a car that was rear-ended and we were hit multiple times i felt two bumps which slugged me forward and caused me to stretch out my right index finger . [doctor] so hitting the car in front of you all made that finger go backwards ? [patient] i do n't really know , i just felt like it felt like i laid on my finger and so i felt like it went back and it's been hurting since about march and it's been like that ever , ever since the wreck happened , so i and i ca n't make a fist but sometimes the pain is unbearable and like even driving hurts . [doctor] okay . so this was march of this year , so maybe about 3 months ago ? [patient] yeah . and it's still swollen . so i was seeing an orthopedist and they sent me to an occupational therapist and i've been doing therapy with them and then they sent me to go back and get an mri , so i went and got the mri then they told me that the mri came back . and i said i had a tear in my finger , but he was n't gon na give me an injection because the injection was going to make the tear worse . [doctor] mm-hmm . [patient] and then after he got the mri he said that i have a tear in my finger and that he did n't want to do surgery , but he would do an injection . then i'm thinking that you told me you would n't do an injection in there and then the occupational therapy says it's because of the tear , and then they do n't want me to keep rubbing the thing and doing things with my hand , so i feel like i'm not getting medical care really . [doctor] hmmm yeah , i see that . [patient] so i came to see if you could do anything for this hand because i am right handed and i kinda need that hand . [doctor] mm-hmm what do you do for a living ? [patient] i'm an x-ray tech . [doctor] wow so do you have any diabetes or rheumatoid arthritis ? [patient] nope . do you take any chronic medications of significance ? [doctor] i do take a blood pressure pill and that's it . [patient] okay and it looks like you suffer from itching with the methyl prednisone ? [doctor] that's correct . alright , well , i'm gon na scoot up closer and just take a quick look at your hand . alright , so lean over here . alright , so on this exam today , we have a very pleasant , cooperative , healthy male , no distress . his heart rate is regular rate , rhythm , 2+ radial pulse . no swelling or bruise , bruising in the palm over the volar surface of his index finger . normal creases , slightly diminished over the tip of the index finger compared to the middle finger . [patient] his index finger rest in a 10 degree pip flexed position alright , is that uncomfortable to correct that and is it uncomfortable now here ? [doctor] yeah when you push on it , yeah . [patient] alright , how about here ? there it's not . [doctor] okay , not as bad . [patient] yeah , it feels little numb . [doctor] gotcha , alright , bend , bend the tip of this finger , bend it as hard as you can , keep bending , keep bending , alright , straighten it out , [patient] alright , and now bend it for me as best you can . my goodness , feels like it's it's tearing in there . okay , okay . well , bend the tip of this finger and bend it as hard as you can , keep bending , alright , straighten that out and now bend it for me as best as you can , [doctor] alright , good . now bend that finger and i'm going to pull , put it down like this and then bend that finger for me , okay , sorry , can you bend it for me ? alright , now make a fist , great , so relax the finger , alright , so just keep it , keep when i bend the finger , we're just going to bend that finger where it meets the hand , is that okay there ? [patient] ow , ah . [doctor] okay , okay , so all the hurt it seems is stretching because you have n't been doing this for so long , so you know what i mean so you're going to have to start really doing that . [patient] well , i've tried , i even bought myself a splint . [doctor] well , but a splint does n't help move you , it actually immobilizes you . [patient] okay , i thought it would straighten it out . [doctor] no , no , so , so you really need to start bending the finger right here for me as hard as you can and keep going , going , alright , so , so you're okay . alright , so i would say the following that there is a partial tear in one of the two flexor tendons . there is the fdp and the fds and the fds is the least important of the two . so the mri shows that it's the fds the flexor digitorum , superficialis which is the least important of the two . [patient] okay . [doctor] now there are two halves of it , so it's the partial tear of one half of a whole tendon . that's not that important and the other one is just fine . so the good one is good ? [patient] yes , correct . so the one that goes all the way to the tip is good . [doctor] okay , good . [patient] yeah , so you know i think what you have got so much scar tissue and inflammation around the fds tendon , [doctor] blocking excursion of these other tendons that they ca n't get through to the pulley . [patient] okay . alright . [doctor] so what i would recommend what we try is a cortisone injection and i would avoid the dexamethasone because i saw you have a little reaction to that . but we could use the betamethasone which is a sellastone i've gotten another methylprednisolone and that itching like crazy . [patient] did it , yeah , this one is water soluble and i think it's fairly low toxicity , but high benefit and i think decreasing the pain will encourage you to move that finger . [doctor] alright , we'll give it a try . good . so you do the shot and it's going to take about 3 to 5 days before it starts feeling better and then probably over the next couple of weeks , it'll start feeling even better . [patient] perfect . [doctor] alright , so take advantage of that . you got ta start moving the finger . you're not gon na tear anything or break a bone because your intensors , extensors are intact . but your collateral ligaments are intact , so you got a sore finger . i'm going to try to help as much as i can with this soreness part and then you have to do all the stiff part . [patient] the lady in occupational therapy tried some maneuvers to straighten the finger out , but it even hurt after i left . the whole thing just swelled up . [doctor] hmmm okay . so it was injured and you had scar tissue and then you had posttraumatic inflammation and so this will help some with all of that . it's not going to make it to where your finger is like my finger does n't hurt at all , but it will make it to where at least tolerable to where you can make some gains and we actually might need to repeat this as well . [patient] well i'll be able to drive , i drove myself here today so . [doctor] yeah , it may feel a little weird , but it's totally safe for you to drive . okay , good . [patient] so for mr . gutierrez , just put that he has a posttraumatic rather severe stenosing tenosynovitis of his right index finger . [doctor] and the plan is steroid injection today , do a trigger injection , but i'm using a cc of betamethasone . so mr . gutierrez , do you have therapy scheduled or set up ? [patient] not at the moment . [doctor] alright , well , i mean you know that you need to move that finger and i think to the degree that they can help you do that . so , i want you to move that finger finger , but i think it would be beneficial for you to have an accountability . [patient] so at least you know to check in with them once a week with somebody . [doctor] okay that's kinda why i'm here for you , tell me what needs to be done , you know . [patient] yeah , so i'll write you out , [doctor] an outpatient prescription . i think if you go back to the same people where you were before , i'm hoping that after this injection , you're going to be able to do a whole lot more with them . so let's do outpatient , once a week for 6 weeks , [patient] and then full active and passive range of motion is the goal with no restrictions . [doctor] alright sounds like a plan . [patient] alright , well i will have the nurse set up the injection procedure and we'll and i'll be back shortly . [doctor] thanks document . right trigger finger injection template , attempted to inject 1 cc of celestone with half a cc of lidocaine however , the patient had a dramatic and violent , painful reaction to the introduction of the needle with contortions of the hand and with dangerously withdrawing the hand with concerns for secondary needle stick . needle was withdrawn . the patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath . we attempted a second time for a similar injection using the same technique with 1 cc of celestone and half a cc of lidocaine . [patient] a small palmar vein bled a scant amount , which was cleaned up and band-aid applied . reassured on multiple occasions that no harm was done to his finger . recommended icing and it this evening and taking ibuprofen . | CHIEF COMPLAINT
Right index finger hyperextension injury.
HISTORY OF PRESENT ILLNESS
Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion regarding evaluation of the right index finger hyperextension injury sustained during a motor vehicle accident in 03/2021.
In summary, the patient was the passenger in a vehicle that was rear-ended. He reports they were hit multiple times as he felt 2 bumps which caused his to sling forward hyperextending his right index finger. He was offered an injection of the A1 pulley region, but he did not want any steroid due to a reaction to dexamethasone that causes his heart to race. The patient was scheduled to see Dr. Alice Davis, but he has not seen his yet. The patient has been seen at Point May Orthopedics, by the physical therapy staff and a physician assistant at that practice. He underwent an MRI of the right index finger because they were concerned about a capsular strain plus or minus a rupture of the "FDS tendon."
The patient states that he is unable to make a fist secondary to pain and swelling in the right index finger. He describes a pulling, tearing sensation in the right index finger. The pain is exacerbated by driving. He notes that he has been wearing a right index finger splint.
The patient denies any history of diabetes or rheumatoid arthritis. He reports only taking medication for hypertension and denies taking any other chronic medications of significance. He also notes methylprednisolone causes his to itch.
Ms. Gutierrez is employed as an x-ray technician.
PAST HISTORY
Medical
Hypertension.
SOCIAL HISTORY
Employed as x-ray technician.
ALLERGIES
Methylprednisolone causes itching.
Dexamethasone causes palpitations.
REVIEW OF SYSTEMS
• Musculoskeletal: Right index finger pain.
• Endocrine: Denies diabetes.
PHYSICAL EXAM
Constitutional
Very pleasant, healthy appearing, cooperative male in no distress.
Neurological
Grossly intact. Slightly diminished sensation to light touch over the right PIP joint of the index finger compared to the middle finger.
Cardiovascular
Regular rate and rhythm.
Musculoskeletal
Exam of the right hand, there is no swelling or ecchymosis in the palm on the volar surface of his index finger. Normal creases are noted. Index finger rests in a 10 degree PIP joint flexed position with discomfort upon correction. Bilateral extremities 2+ radial pulses.
RESULTS
X-rays today, 4 views of the right hand, show no bony abnormalities. Joint congruency throughout all lesser digits on the right hand. No soft tissue shadows of concern. No arthritis.
MRI of the right index finger performed on 04/24/2021. Independent review of the images shows focal soft tissue swelling over the right index MCP joint, partial-thickness tear of the right FDS, and fluid consistent with tenosynovitis around the FDP and FDS tendons. Radial and ulnar collateral ligaments of the index MCP joint were intact as was the MCP joint capsule. The extensor tendons were also deemed intact.
ASSESSMENT
• Stenosing tenosynovitis of right index finger.
Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion of his right index finger hyperextension injury sustained during a motor vehicle accident in March of this year. The findings of his examination are consistent with rather severe post-traumatic stenosing tenosynovitis.
PLAN
The patient and I had a lengthy discussion regarding his history, symptoms, and radiographic findings. We discussed the pathophysiology and natural history of stenosing tenosynovitis and the anatomy of the flexor tendons and pulley system in the hand. I explained to the patient that the flexor digitorum superficialis tendon was clearly intact and that He is suffering from post-traumatic inflammation around the flexor digitorum superficialis tendon blocking excursion of the flexor tendons to the A1 pulley.
Treatment options were discussed including conservative management with corticosteroid injections and their statistical effectiveness. Surgical correction was also briefly discussed, although I recommend exhausting non-operative measures with a minimum of 2 injections before proceeding with surgery. I recommended a right index trigger finger cortisone injection today, and the patient elected to proceed. I also recommend that the patient report to occupational therapy once a week for the next 6 weeks to work on full active and passive right index finger range of motion with no restrictions.
The patient verbalizes understanding with the treatment plan and agrees. All questions were answered to the patient's satisfaction today.
PROCEDURE
Right index trigger finger injection.
The patient understands the risks and benefits and elected to proceed, signed consent obtained. An attempt was made to inject 1.0 cc of Celestone with 0.5 cc of lidocaine. However, the patient had a dramatic and violent painful reaction to the introduction of the needle with contortions of the hand and with dangerously withdrawing the hand with concerns for secondary needle stick. Therefore, the needle was withdrawn. The patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath. We attempted a 2nd time for a similar injection using the same technique with 1.0 cc of Celestone and 0.5 cc of lidocaine. There was a small palmar vein that bled a scant amount, which was cleaned up off the back of the patient's hand. A Band-Aid was applied. He was reassured on multiple occasions that no harm was done to his finger. I recommended icing it this evening and taking ibuprofen.
INSTRUCTIONS
Occupational therapy as prescribed.
|
VS031 | virtscribe | [patient] good morning miss reyes . [doctor] good morning . [patient] how are you doing ma'am ? [doctor] i'm doing well dr. , how are you ? [patient] i am fine , thank you . so you've been having some problems with your right hip ? [doctor] yeah . [patient] okay and where are you hurting ? can you show me ? [doctor] right in the groin area . [patient] okay and this has been going on since february 2020 ? [doctor] yeah . [patient] okay and is it worse with movement ? [doctor] and i almost fall back okay so kind of grabs you yet okay this all started when you were walking while walking around the infusion room okay so it started if i took a step back or you know sep like that now it happens anywhere . [patient] okay , so now it hurts whenever you move . [doctor] it hurts when i pivot . [patient] okay , so if you pivot , then it hurts , got it . [doctor] sometimes do it sometimes it will go and sometimes it will do it several times in a row several times in a row okay and sometimes i fall . [patient] okay and you rate the pain to range from 2-7 out of 10 ? yeah , that's correct . okay and are you experiencing fever or chills ? no . okay and any tingling or numbness ? no . [doctor] and have you had any problems with your bowel or bladder ? [patient] no . [doctor] okay and if you stay still , do you feel better ? yes , but i do n't want to stay still . [patient] i understand , no problem and for past medical history , do you have anything going on ? [doctor] pcos i had infertility gallbladder removed but that that okay and for family history it looks like there is high blood pressure diabetes . [patient] thyroid disease , heart disease , kidney disease , and gastric ulcers for your current medications , it does n't look like you're taking anything at this time and you are allergic to percocet , vicodin and reglan and it looks like you had intentional weight loss , [doctor] yes i've lost 110 pounds . [patient] that is awesome and how did you do that with weight watchers great and how many months have you been participating in weight watchers ? [doctor] i started in 2018 and i've been at my current weight for a little over a year . [patient] that is awesome . [doctor] yeah , thank you . [patient] yeah very good and congratulations and so for social history , it looks like you work at an infusion center . [doctor] yes . [patient] okay and you live with your roommate , no history of tobacco and alcohol intake less than five drinks per month . [doctor] that's correct . [patient] take a look at your hip . [doctor] okay . [patient] please use my general physical exam template . physical exam miss reyes is a pleasant 56-year-old woman who is 5 feet 6 inches in height , weighing 169 pounds , [doctor] blood pressure is 115/75 . pulse rate is 67 . ankles , no ankle edema is noted . no calf tenderness . okay miss reyes , can you go ahead and stand up for me please and take a couple of steps . [patient] great and can you walk on your tippy toes ? [doctor] good , okay and can you walk on your heels , kind of a heel walk and toe walk are intact . go ahead and turn around please . okay . examination of the cervical spine , any pain here now ? [patient] no . [doctor] okay . no tenderness . look at your right and your left and then over to the right . then go ahead and look up and look down and look straight ahead range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ? [patient] no . [doctor] okay . skin is intact . no midline tenderness to palpation . go ahead and lean back and lean to your right to your left . does that hurt at all ? no . [patient] okay , great and go ahead and bend forward and then come back up and that does n't bother you ? [doctor] no , i did or do have several bulging disks . [patient] okay , but you're not hurting right now ? [doctor] no , the weight loss has really decreased all the pain . okay . range of motion is decreased in exertion . lateral flexion without pain . any pain when i push ? [patient] no . okay . you can go ahead and sit down please . no pain ? [doctor] no . [patient] okay . sacroiliac signs are negative . examination of the hips , [doctor] trochanteric is nontender . go ahead and lift your knee up . does that bother you ? [patient] just a little bit . [doctor] okay . little bit and then back one probably bothers you ? right there like the area . [patient] okay . how about this way ? not too bad ? [doctor] no . okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . [patient] okay , go ahead and keep it up , do n't let me push it down . does that hurt ? right there . okay . resisted right hip flexion causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ? [doctor] yeah . okay . motor control is normal in the lower extremities . go ahead and lift your knee up . [patient] okay . [doctor] okay . lift it up , any pain ? [patient] no . [doctor] okay and this one ? [patient] yeah . [doctor] and squeeze your knees together push it out and kick your leg out straight now go ahead and bring it back and kick it out straight again and go ahead and lean back , keep it loose okay all set and go ahead and sit up now okay , thank you . [patient] you're welcome . so what i think we're dealing with is right hip degenerative joint disease . [doctor] okay . [patient] and we do have some options , so first is to start some low impact exercises . i can provide you with a handout with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain . [doctor] i do n't love that idea , but i will give it a try . [patient] okay , that would be great and we can also try a cortisone injection into the right hip joint to see if that offers any relief . [doctor] i would like to definitely get that injection . [patient] okay . we can take care of that today while you are here and then schedule a follow-up appointment in 3 months to see how you are doing and then receive another injection if needed . [doctor] okay that sounds good . [patient] okay and here are the risks associated with getting the injection please just take a moment to review it and consent to the shot . [doctor] i'm good . [patient] great . we'll get that set up for you . alright , well i hope things feel better and we will see you back here in 3 months . [doctor] thank you . have a nice day . [patient] thank you so much , you as well . [doctor] deep tendon reflexes 1+ throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list . [patient] next radiographs , mr arthrogram of the right hip done june 3 , 2021 show high grade chondromalacia involving the anterosuperior right acetabulum , with subchondral marrow edema and cyst formation . , plan , options include low impact exercise program , use of an nsaid and use of the cane to offload the right . we discussed that she'd like to proceed with a cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile , and covid . she understood and decided to proceed with the injection . [doctor] she will follow up with me in 3 months for another injection if needed . end of dictation . | CHIEF COMPLAINT
Right hip pain.
HISTORY OF PRESENT ILLNESS
Elizabeth Reyes is a 56-year-old female who presents for the evaluation of pain in her right hip and groin region. Her symptoms started on 02/2020 and has progressively worsened. She is employed as an RN and notes that her symptoms began while she was working and walking around the infusion room at Johnson. Initially the pain would only happen when she took a step back, but the pain has progressed and now occurs with any type of movement involving her right hip and groin. She describes that her hip will sometimes “catch” when she moves, causing her to fall on occasion. The pain improves when she is still and stops moving. She rates her pain as 2-7/10.
Starting in 2018, the patient intentionally lost 110 pounds through Weight Watchers. She has maintained the weight loss and her weight has been stabile for the past 1 year. She has a history of several bulging discs, but the pain has significantly reduced due to her weight loss. Today, she reports no back pain.
She denies fever, chills, new onset of bowel or bladder dysfunction, tingling or numbness.
Opioid Assessment
Opioid Use: No.
Pain Assessment
Pain is frequent.
Quality of Pain: Right hip catches.
Intensity of Pain Using VAS 0-10 Scale (0 = No pain, 10 = Worst imaginable pain)
• Current Pain Intensity: 2/10.
• Average Pain Intensity Over the Past Week: 4/10.
• Pain at Best: 2/10.
• Pain at Worst: 7/10.
Relieving Factors: Lying down, sitting.
Aggravating Factors: Walking, pivoting, turning, any movement engaging right hip.
PAST HISTORY
Medical
PCOS.
Surgical
Cholecystectomy.
SOCIAL HISTORY
Works at the infusion center at Johnson. Lives with a roommate. Denies tobacco use. Limits alcohol intake to less than 5 drinks per month.
FAMILY HISTORY
Hypertension.
Diabetes.
Thyroid disease.
Kidney disease.
Gastric ulcers.
CURRENT MEDICATIONS
NSAID PRN by mouth.
ALLERGIES
Percocet.
Vicodin.
Reglan.
VITALS
Blood pressure: 115/75
Pulse: 67.
Height: 5’6.
Weight: 169 lb.
PHYSICAL EXAM
Constitutional
Pleasant.
Integumentary
Skin is in tact.
Musculoskeletal
Extremities: No bilateral ankle edema or calf tenderness.
Examination of gait: Heel-walk and toe-walk are intact.
Cervical spine exam: No tenderness is elicited. Range of motion is full in all planes without pain. Spurling's test is negative.
Lumbar spine exam: Range of motion is decreased in extension and lateral flexion without pain. No tenderness is elicited in the midline.
Sacroiliac joint exam: Bilateral sacroiliac joints are nontender to palpation.
Bilateral hip exam: Range of motion is decreased in the right hip with pain in the groin on internal and external rotation. Resisted right hip flexion causes pain in the right groin region. Bilateral trochanteric regions are nontender to palpation.
Neurological
Motor bulk and tone are normal in both lower extremities. Motor strength testing reveals no focal motor weakness in the lower extremities. Deep tendon reflexes are 1+ throughout. No focal sensory deficit is noted.
RESULTS
MR arthrogram of the right hip completed on 06/03/2021 reveals evidence of high-grade chondromalacia involving the anterosuperior right acetabulum with subchondral marrow edema and cyst formation.
ASSESSMENT
• Right hip degenerative joint disease.
PLAN
I discussed the clinical and radiological findings with the patient. Treatment options discussed are low impact exercises, use of analgesics as needed, and use of a cane to offload the right hip. She would like to proceed with a cortisone injection into her right hip joint. We will administer the injection today. I reviewed the procedure in detail, including the risks of the injection related to the use of steroid in the COVID setting. She understands the risks and would like to proceed with the injection.
INSTRUCTIONS
Schedule a follow up appointment in 3 months to assess her pain. If needed, a second injection may be administered.
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VS032 | virtscribe | [doctor] dictating on donald clark date of birth 03/04/1937 . chief complaint is left arm pain . hello , how are you ? [patient] good morning . [doctor] it's nice to meet you . i'm dr. miller . [patient] it's nice to meet you as well . [doctor] so i hear you are having pain in this arm , is that correct ? [patient] that's correct . [doctor] okay and it seems like it's worse at night ? [patient] well right now the hand is . [doctor] mm-hmm . [patient] and the thing started about 2 weeks ago , i woke up about 2:00 in the morning and it was just hurting something awful . [doctor] uh uh . [patient] and then i laid some ice on it and it finally did ease up . [doctor] okay , that's good . [patient] so i got up , i sat on the side of the bed and held my arm down thinking it would like help the circulation , but it did n't . [doctor] okay , i see . [patient] and so after a while when it eased off maybe about four or 5 am i laid back down and it did n't start up again . [doctor] mm-hmm okay . [patient] i went back to sleep but for several nights this happened like over and over , so i finally went to see the doctor and i do n't really recall her name . [doctor] okay . yeah , i think i know who you're talking about though . [patient] she is the one who sent me to you , so i , i would , i would think so , but when i went to her after the third time it happened , then she checked me out , she said it was most likely coming from a pinched nerve , [doctor] probably do you notice that moving your neck or turning your head seems to bother your arm ? [patient] no . [doctor] okay . is moving your shoulder uncomfortable at all ? [patient] no . [doctor] and do you notice it at other times besides during the night ? [patient] some days if it bothers me at night , then the day following it usually will bother me some . [doctor] okay and do you just notice it in the hand or does it seem to be going down the whole arm ? [patient] well it starts there and goes all the way down the arm . [doctor] okay . have you noticed any weakness in your hand at all ? [patient] yes . [doctor] okay like in terms of gripping things ? [patient] yeah . [doctor] okay . [patient] this finger i hurt it sometime ago as well . [doctor] really ? [patient] yeah , it does n't work properly or it works very rarely . [doctor] gotcha and did i hear that she gave you some prednisone and some oral steroids or ? [patient] well she gave me some numbing medicine , it helped a little bit . the other two were a neck pill and gabapentin , [doctor] you should have a full list in your notes though since then it has n't really bothered me at night also just see now i am a va and him 1 % disabled from this leg issues from the knees down to my feet okay is it neuropathy gotcha , that is good to know . alright , well , let's go ahead and take a look . [patient] okay . [doctor] alright , so to start , i'm gon na have you do something for me just go ahead and tilt your chin as far as you can down to your chest . okay , good and now go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay and now come back to normal , just look and turn your head as far as you can that way great and now as far as you can towards that wall , does not seem to bother you at all now well actually i do feel little strain okay so you feel it in the neck a little bit yet is a little strain okay now squeeze my fingers as hard as you can with both hands great now hold your arms like this . [patient] okay . [doctor] and i'm going to try to straighten your arms and try and keep them as stiff as you can , do n't let me straighten it . okay , good , good . now when i am just touching your hands like this , does it seem to feel about the same in both hands ? [patient] yes . [doctor] okay . alright so i do agree with betty more than likely this seems like it would be coming from your neck that's the most common reason that causes what what you're experiencing . and i looked at an x-ray of your neck and you do seem to have a lot of arthritis there and there does seem to be potential for a disc to be pushing on a nerve . and now what i do n't have is an mri which would show me kind of exactly where the nerve roots are getting pinched off . [patient] i see . [doctor] so gabapentin can help a little bit with the nerve pain and what i would like to do is potentially set you up for an epidural and what that is is it it's a focused anti-inflammatory medicine excuse me , that works behind the nerve roots , that nerve roots that we are thinking might be getting squished off . it can often help alleviate your symptoms and i do need to get an mri of your neck . i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see . right where i need to put the medicine for your epidural . what do you think of that ? [patient] i think that sounds good to me . [doctor] okay , good and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list . [patient] no , i do n't . [doctor] okay good and what i would have you do is continue with the gabapentin are you taking 300 or 100 ? [patient] i'm not sure my lady friend helps me handle this stuff . [doctor] okay . [patient] i am taking eliquis though . [doctor] okay so whatever you are doing , you can just keep doing it and i'm going to set you up for the epidural and imaging study just so i know right up with the medicine and i will follow up with you after that and we can do the shot just to make sure your arm is feeling better sound good . [patient] sounds good . for the last couple of nights though my neck has not been bothering me . [doctor] okay so presumably what's happening then is when you're sleeping , your neck is kinda gets off tilt tilter and it compresses the nerve roots there . now if you think you're doing fine , we could hold off , but at the very least , i'd like to update that mri of yours and see what's going on because probably this is something that will likely flare up again . [patient] yeah it it has been for the last week , so i understand . okay , alright , well , do you want to do that work-up and do the epidural or do you think you're doing fine and do you wan na wait ? well my hand is still bothering me . okay . so you're saying your neck is not bothering you , but the hand is . okay , so then let's just stick with the plan . [doctor] mri of the neck , so we can see where the nerve roots maybe compressed that's giving your hand the issue and then we are going to set you up with the epidural . [patient] okay , sounds good . [doctor] alright , so keep going with the gabapentin . i will order the imaging of your neck and the shot will hopefully help some with those symptoms in your hand and then we will follow up afterwards . [patient] alright , is the mri today ? [doctor] you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute and then roy will come in and get things scheduled as soon as we can . alright . [patient] alright , well , it was nice meeting you my friend . [doctor] you as well , thank you . physical exam , elderly white gentleman presents in a wheelchair , no apparent distress per the template down through neurologic , 1+ bilateral biceps , triceps , brachioradialis , reflexes bilateral , all negative . follow up and take out the lower extremities . gait not assessed today . strength and sensation is per the template . upper and lower extremities , musculoskeletal , he is nontender over his cervical spine . he does have mildly restricted cervical extension , right and left lateral rotation which is symmetric which gives him mild lateral neck pain , but no radic radicular pain . spurling's maneuver is benign . paragraph , diagnostics , cervical x-rays 6/4/2021 . cervical x-ray reveals significant disc degeneration at c5-6 and to a lower extent c4-5 and c3-4 . significant lower lumbar facet arthropathy c6-7 and c7-t1 is difficult to visualize in the current x-rays . paragraph , impression , # 1 , left upper extremity neuropathy suspicious for cervical radiculopathy , possible contribution of peripheral neuropathy . # 2 , neck pain in the setting of arthritis , disc degeneration . paragraph , plan , i suspect that this is a flare of cervical radiculopathy . i'm going to set him up for a cervical mri and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners . | CHIEF COMPLAINT
Left arm pain.
HISTORY OF PRESENT ILLNESS
He reports that his left arm pain began approximately 2 weeks ago. He woke around 2:00 am with intense pain in his left arm and hand. He applied ice and after 2-3 hours, the pain improved and he was able to go back to sleep, the pain did not return until that evening. After several nights of experiencing the left arm and hand pain, he was seen by Betty Ross, PA-C. She suspected a pinched nerve and completed x-rays of the cervical spine, prescribed gabapentin and prednisone, and referred the patient to us. The patient has benefited from the gabapentin and prednisone, reporting improvement of pain at night.
The pain initially was encountered at night, but the patient notes that the symptoms carry into the next day. He denies pain when moving his neck, turning his head, and moving his shoulder.
Mr. Clark does report a history of a left finger injury, stating “it rarely works”, and neuropathy in one leg from his knee to his foot which he receives 1% disability for. The patient is a veteran.
PAST HISTORY
Medical
Peripheral neuropathy.
SOCIAL HISTORY
The patient is a veteran and receives 1% disability.
CURRENT MEDICATIONS
Gabapentin tablet.
Prednisone tablet.
PHYSICAL EXAM
Constitutional
Elderly Caucasian male in no apparent distress. Presents in wheelchair.
Neurologic
Upper extremities: 1+ bilateral biceps, triceps, brachioradialis, reflexes bilaterally, negative. Negative Hoffman's
Gait: Not assessed today.
Strength
Upper extremities: Normal throughout the biceps, triceps, deltoid, grip strength, and finger abduction, bilaterally.
Sensation: Intact to light touch throughout the upper and lower extremities.
Musculoskeletal
Cervical: Nontender over cervical spine. Mildly restricted cervical extension and right and left lateral rotation, which is symmetric, which gives him mild lateral neck pain, but no radicular pain. Spurling's maneuver is benign.
RESULTS
X-ray Cervical Spine, 06/04/2021.
Impression: Significant disc degeneration at C5-6 and to a lesser extent C4-5 and C3-4. Significant lower facet arthropathy. C6-7 and C7-T1 are difficult to visualize in the current x-rays.
ASSESSMENT
• Left upper extremity neuropathy, suspicious for cervical radiculopathy, possible contribution of peripheral neuropathy
• Neck pain in the setting of arthritis and disc generation
PLAN
I suspect that this is a flare of cervical radiculopathy. I am going to set him up for a cervical MRI. We will tentatively plan for a left C7-T1 epidural afterwards, although the exact level will be pending the MRI results. He will continue his home exercise program as well as twice daily gabapentin. We will follow up with him afterwards to determine his level of relief. He denies any blood thinners.
This plan was discussed in detail with the patient who is in agreement.
INSTRUCTIONS
Continue home exercise program and twice daily gabapentin. Schedule MRI and epidural injection. Follow-up after epidural. |
VS034 | virtscribe | [doctor] patient is pamela cook , medical record number is 123546 . she is a 36-year-old female post bilateral reduction mammoplasty on 10/10/2020 . doing well , it's good to see you , how you've been ? [patient] i've been doing good . [doctor] great how about your breasts today , doing alright ? great are you having any chills fever nausea or vomiting now good peak real quick sure how is life otherwise pretty good nothing new just enjoying summertime okay how is your family ? [patient] very good . [doctor] good alright i'm gon na take a look at your breast now if you would just open up your gown for me everything looks good has her back pain i'm not really having any more any hard spots lumps or bumps that you've noticed i did when i came in last time when i saw your pa ruthsanchez in march she said i she said she found a lump right here under my left breast but i have n't felt it since then but i did the massages echo that that is good is probably just a scar tissue but everything looks good and your healing wonderful so i told her that the scar here was kind of bothering me and i got forgel i was using it every day but i do n't think i needed now yeah , that scar did widen a little bit . lem me take a closer look . hang on . this one widened a little too uh . your incisions are well healed though with no signs of infection or any redness on either breast , so i'm not concerned . but this one just bothered me a little bit more understanding culture gown now the only thing that is really going to help out that is to to cut it out and re close it . [patient] [doctor] and you do n't want that uh ? [patient] i mean not right now . [doctor] you want to come back and revisit maybe 6 months yet ellipta that i still have n't i still have some more of the gel and i can try using that again okay . keep doing that twice a day , the gel is going to lighten the color a little bit which is already pretty light but just in that area and it's it's high tension so it's going to rub a little bit . [patient] yeah but it kind of bothers me a little bit . [doctor] i do see that like i said the only way to really fix that is to cut it out with a 6 months and then will go from there semi a plan but we have n't had a full year yet i know i would n't do any revisions anyway for scar tissue until we're at least a year out anyway . [patient] okay . [doctor] so let's wait those 6 months , you can keep using the mederma scar gel twice a day , massage and scar gel will help for the scars . you can put it on other scars too if you need . [patient] okay . [doctor] so that's what i would do . let's just get some pictures today , so we can keep up with them and keep an eye on this scars and then we will go from there . [patient] sounds good . [doctor] alright , well it's good to see you , i'm glad you're doing well . [patient] yeah , same here . [doctor] alright , well , i'm gon na tell the front desk 6 months and we'll revisit those scars . [patient] alright . [doctor] thank you . i'm gon na come and get your photos now , okay ? [patient] okay . | CHIEF COMPLAINT
Follow up bilateral reduction mammoplasty.
HISTORY OF PRESENT ILLNESS
Pamela Cook is a 36-year-old female who is returning for a postoperative visit. Status post bilateral reduction mammaplasty 10/10/2020.
The patient was last seen in clinic by Ruth Sanchez, PA in 03/2021 at which time there was a lump along the left breast, and she was advised to perform massages.
Today, Ms. Cook reports she is doing well and that her breasts feel great. She is no longer suffering from back pain. The left breast lower incisional lump from last visit has resolved with massaging and use of scar gel. She reports that the scar on her breast has been bothersome. The patient denies fever, chills, nausea, or vomiting.
CURRENT MEDICATIONS
Mederma scar gel to incision.
PHYSICAL EXAM
Breast
Bilateral breast incisions well healed with widening of the scar tissue. No signs of infection or erythema.
ASSESSMENT
• Status post bilateral reduction mammoplasty.
Pamela Cook is a 36-year-old female who is status post bilateral reduction mammaplasty on 10/10/2020. There is some widening of the scar tissue bilaterally.
PLAN
- Obtain bilateral breast photos today to monitor scarring.
- Continue Mederma scar gel and incisional scar massage twice daily.
INSTRUCTIONS
Follow up in 6 months to reevaluate scars.
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VS039 | virtscribe | [doctor] next patient is paul , date of birth is january 15 , 1962 . this is a 59-year-old hiv positive gentleman here for hypogonadism . patient was last seen on november 24 , 2020 . he is . [patient] his notable things are # 1 , he is on 1 ml every 10 days . his levels were less than 300 to begin with . he is on finasteride currently . he also takes cialis daily , so he takes all his pills just from me , patient's other area of concern is gynecomastia , which is , which we will discuss with him today . his last psa was 0.66 and his last testosterone was greater than 1500 . [doctor] hey , how are you today ? [patient] alright , how you been ? [doctor] i'm good . [patient] good , good . [doctor] have you lost some weight or you at least putting on some muscle , you look trump . [patient] no , i think i'm pretty much the same as i've always been . [doctor] really ? okay , maybe it's just your black shirt , makes you look then . [patient] yeah , i guess that's it . [doctor] so health wise , how is everything going ? [patient] good , the testosterone is going well . [doctor] that's great . [patient] helped me out , i feel good , more vigorous , sleeping well and i think it's having some positive effects , not so much physically because like i said , i've i've been this way my whole life , but i'm seeing some good improvements in my blood work . [doctor] okay , well , that's good . [patient] so the finasteride i am only taking half a pill , it's the 5 mg one . [doctor] yeah , i remember you telling me that . [patient] and cialis on the days i work out , i take 5 mg , otherwise i take 2-1/2 mg pills , but i have been out of it . [doctor] okay . [patient] but overall i'm doing well . i'm actually taking the correct steps to get my life together . [doctor] good . it's always great to hear . let's look i'm gon na listen to your heart and lungs . [patient] okay . [doctor] please use my general exam template alright just take a few breaths . [patient] okay . [doctor] now . alright everything sounds good , no concerns there . [patient] great . so i wanted to show you something . [doctor] sure . [patient] look at this . [doctor] okay , this is your cholesterol . [patient] yeah , my cholesterol and triglycerides , i used to have high triglycerides , you see they were 265 mg/dl , then i took my first dose of the testosterone on the 28th . [doctor] right . [patient] now 5 months later look at my numbers . [doctor] wow , that's remarkable . [patient] this is the test , it's the only change . i do n't know , i have n't honestly seen many guys over the years that have cholesterol problems and this i mean there is a big correlation between diabetic control and testosterone replacement meaning those who get good levels of their tests see their diabetic control improve . [doctor] yeah . but i have n't seen a lot of data on the impact on cholesterol . regardless we will take it . [patient] i agree . i was very impressed with my triglycerides and was just wondering if the test may be what's helping . [doctor] yeah , that's an unbelievable difference . [patient] 145 mg/dl from 265 mg/dl is awesome . i also read that it it's cardioprotective . [doctor] absolutely . [patient] my red blood cell count has increased . [doctor] yeah , i saw that . it's fine though . [patient] stable . [doctor] your psa a today is also is good also . it's 0.6 i think . [patient] yeah is it ? [doctor] yeah , it was 0.5 last year and anything under four is good . [patient] nice , such good news . [doctor] so it just needs to be checked every year or so . [patient] so in terms of estrogen control , i've been hearing that indol three carbonal or broccoli extract , supposedly can improve my estrogen levels . have you ever heard of it ? yeah , i've heard of it , but i have n't had anybody consistently use it . i mean your levels are fine and we checked your estradiol and it was not elevated , so . okay . [doctor] i would argue that we could test that in the fall if you want , but we do n't need to do anymore tests anymore than test once a year , excuse me . [patient] okay . what about increasing my testosterone to 175 mg . i'm at 140 now . [doctor] well , your levels are high . [patient] are they right now ? [doctor] well , i mean they were last time . [patient] yeah , but i just just injected though where i had right before that was taken . [doctor] i know , i know you had then . when did you inject this time ? [patient] i figured i'm on my eighth day today . [doctor] okay . [patient] so i'm due to dose on thursday or friday . [doctor] alright . [patient] i have a little med calendar and i put checks and teas on it , that helps me . [doctor] that's a great idea . so look the biggest issue i've seen even if your levels today are around 700 is that your peaks are getting greater than 1500 , putting you at a higher chance of needing to come off due to blood thickness and your risk will only go up the higher the dose that we go on . [patient] okay . [doctor] you look well , your levels are good and you are feeling well . [patient] yeah , i'm feeling good . [doctor] i'm going to be blunt . unfortunately this happens often where you are feeling good but you want to feel really good . i mean i get it , and this is why people get into problems with this stuff , right ? it's like back in the day when it was n't prescribed by doctors and people would get it at gyms and stuff and they would take huge doses and then they would have a heart attack at 50 . [patient] yeah , they have to be taking a lot . [doctor] likely they are taking more than testosterone but still . [patient] and they are taking stuff for a long time . [doctor] true but right now i would not change your dose . [patient] okay . [doctor] makes sense ? [patient] it does , i appreciate the discussion . [doctor] no problem . what pharmacy are you using ? have you changed it or anything ? [patient] no changes , i use walmart pharmacy . i do need more cialis and finasteride . [doctor] okay . [patient] i would prefer the paper prescription . [doctor] for all of them ? [patient] sure . [doctor] alright , we will do . let me go get your prescriptions . [patient] okay , thank you . | CHIEF COMPLAINT
Hypogonadism.
HISTORY OF PRESENT ILLNESS
Mr. Paul Edwards is a 59-year-old male, an established patient, who presents to the clinic today for hypogonadism. He was last seen on 11/24/2020. The patient’s history includes positive for HIV, and today he is concerned with gynecomastia.
The patient is doing well, overall, and feels the testosterone is helping. He reports weight stability, feels lively, good, more vigorous, and he is sleeping well. He also thinks the testosterone is having a positive effect on his blood work. He endorses that his triglycerides have always been elevated and adds that they were as high as 265 mg/dL. The patient presented a copy of his bloodwork, showing a significant decrease in his cholesterol after 5 months. Mr. Edwards questioned if the changes in his blood work were due to the testosterone. He also noted that his red blood cell count has not increased. The patient inquired about possible benefits of Indole-3-carbinol, which is a broccoli extract for estrogen control.
Currently, the patient is dosing 140 ng/dL of testosterone per week and inquired if his dose could be increased to 175 ng/dL. He recalled that he had recently injected testosterone before his last testosterone blood work was performed; last testosterone levels were greater than 1500 ng/dL. The patient confirms continued daily use of Finasteride and Cialis, prescribed by me, and stated he needs a refill for both.
Mr. Edwards mentioned he is taking correct steps to get his life "together." He also uses a med calendar to help with medication compliance.
PAST HISTORY
Medical
HIV
SOCIAL HISTORY
Utilizes med calendar to support medication compliance.
Actively trying to get his life together.
CURRENT MEDICATIONS
Cialis 5 mg tablet by mouth on days he exercises, 2.5 mg tablet by mouth on days without exercise.
Finasteride 5 mg half tablet daily.
Testosterone cypionate 140 mg.
RESULTS
PSA 0.6 ng/mL.
Triglycerides 145 mg/dL.
Total testosterone 1500 ng/dL, 11/24/2021.
ASSESSMENT
• Hypogonadism.
PLAN
I recommend maintaining current management. The patient’s last testosterone levels were greater than 1500 ng/dL, although this level was likely related to his recent injection. He requested an increase to his testosterone cypionate from 140 mg to 175 mg, which I denied due to his already high testosterone levels. I counseled the patient on the risks associated with high testosterone levels and Indole-3-carbinol and it’s lacking evidence to support his estrogen levels. The last time his estradiol levels were checked, they were normal; recommend annual screening.
I provided paper prescription refills for Cialis and Finasteride.
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