[doctor] uh , mrn49282721 . patient's name is jacqueline miller . use last visit exam where appropriate .
[doctor] hi , how are you doing , jacqueline ?
[patient] i'm pretty . good . how are you ?
[doctor] good as well . so it sounds like we're , um , under good control right now .
[patient] yes . it's doing much better .
[doctor] good , good . do you have any rash leftover ?
[patient] yeah , i have a- a small bit leftover . i started using , uh , doxycycline only one a day because i think the pharmacist said if it's getting better , to just limit it to once a day .
[doctor] okay , that sounds good .
[patient] but i was taking it twice a day and i did notice a lotta improvement .
[doctor] okay .
[patient] and then when i started doing it only once a day , it seems the same and it's not continuing to get better . so it's kinda plateaued a little bit .
[doctor] i see . um , are you breastfeeding at this time ?
[patient] no , i'm not right now .
[doctor] okay , good . so you- you should not be breastfeeding while you're on that medication .
[patient] yeah , actually i stopped breastfeeding and then asked for the doxycycline at that time .
[doctor] okay . even with the doxycycline , you can keep using the elidel .
[patient] okay . and i did n't take the elidel because when i read about it i got worried . so i wanted to just try the doxycycline and see .
[doctor] okay . so we can talk about the elidel . a lot of the things you read about is not actually relevant to the cream or ointment form , but it's about the oral form that's used in really high doses , longterm , after people have a heart transplant or a kidney transplant or something like that .
[patient] okay . i did n't realize that .
[doctor] yeah , and when you suppress the immune system that hard for that long , it can predispose you for developing cancers like hematologic type cancers . it does n't apply to as-needed use of the medicine , a cream or an ointment , okay ?
[patient] okay . then i can resume taking - taking the doxycycline twice a day again ?
[doctor] so let me clarify . what exactly are you using ? and then we'll look at you and figure out , okay ? so you're using the sulfacetamide wash ? uh , how frequently are you using that one ?
[patient] twice a day .
[doctor] okay , and that's not drying you out too much ?
[patient] no , that's fine .
[doctor] okay . and you're using the metro cream ?
[patient] yes .
[doctor] how often are you using that one ?
[patient] after my face wash , i immediately apply the cream .
[doctor] okay . and then , are you using any other kind of lotions or anything ?
[patient] no .
[doctor] so you're not using the cetaphil cleanser ?
[patient] i'm not .
[doctor] okay . and no neutrogena wipes ?
[patient] no wipes .
[doctor] okay . um , and then what about , um , any lotions that you're using ?
[patient] i'm not using any lotion right now , just those two .
[doctor] no lotion , okay . so that may be something else we should add in , a lotion to just help moisturize . but we'll see .
[patient] okay .
[doctor] um , and then again , when did you go down to just taking the doxycycline once a day ?
[patient] that was last week . so the first two weeks , i did twice a day .
[doctor] okay .
[patient] and then i started seeing improvement , and then i changed to just once a day .
[doctor] okay . let me take a look at your face here . i'm gon na describe for the transcriptionist what i'm seeing . you're fitzpatrick skin type iv , meaning you're not going to burn , you're going to sun tan , um , essentially , iv to v. and then on bilateral medial cheeks , there are a few really faint erythematous papules and just maybe a little bit of redness around and underneath your nostrils . so you're right , it's not totally gone .
[patient] yeah .
[doctor] i think i would go ahead and go back to twice a day , every day , with the doxycycline .
[patient] okay .
[doctor] uh , but i would pickup the elidel too .
[patient] okay , i can do that .
[doctor] i mean , out of known risks associated with medications , topicals are usually safer and preferable to oral medications . with that being said , doxycycline is low risk .
[patient] it is ? okay .
[doctor] um , and doxycycline can give you bad upset stomach or heartburn . um , it will make you sunburn , even if you never sunburn , so you have to protect yourself .
[patient] yeah , i mean , i feel sun sensitive whenever i go out , so i am taking all the precautions , with wearing a hat and all of that .
[doctor] great . i just wanted to make sure you knew about that .
[patient] yes , i did . thank you .
[doctor] all right . but i think to help get rid of it sooner rather than later , if insurance will cover the elidel , pick it up and start using it .
[patient] yeah , i did check . the insurance is not covering it .
[doctor] it's not ? okay . well , let's look around really quick because if you use a goodrx coupon , it will be around 30 to $ 40 or something .
[patient] okay .
[doctor] let's see .
[patient] so with your coupon , it was around $ 850 or something .
[doctor] ugh , yeah . that's way too much .
[patient] i agree . and- and because i also looked at the eucrisa that you recommended in my notes , and if it's still ex- if it's still expensive , i could try that instead .
[doctor] yeah , so it ... actually ... it is actually more expensive . i think the prices fluctuate .
[patient] okay .
[doctor] because now it's showing the cheapest of $ 70 , and when i looked before , it was around 30 to $ 40 .
[patient] yeah . if it was around $ 200 , i would've picked it up . but it was coming to around $ 850 after insurance .
[doctor] okay . so i've found the cream form . we could try ointment form .
[patient] you mean the tacrolimus ?
[doctor] yeah , mm-hmm .
[patient] okay .
[doctor] so if we send it to pick'n save or metro market ... let's see where else .
[patient] can you do the metro market ?
[doctor] yeah . let me put in the prescription and we'll see what we can find .
[patient] sure .
[doctor] pharmacy is what i'm trying to say .
[patient] okay . but it's not a steroid , right ?
[doctor] correct , it's not a steroid .
[patient] okay , good .
[doctor] it's called a calcineurin inhibitor . it's kinda like a steroid in that it calms inflammation .
[patient] okay .
[doctor] but it's not a steroid , so do n't use steroids on your face , for sure , as they'll make this kind of rash worse . but also , steroids carry the risk of causing thinning of the skin .
[patient] all right .
[doctor] these medications do n't cause thinning of the skin and they're not going to cause some other kind of rash . um , the thing to know is that sometimes five to 10 minutes after you put it on , it can cause this weird kind of tingly or needle-like sensation or make it redder or flush . but it should only last a few seconds and then go away . it's not an allergy or anything bad .
[patient] okay . got it .
[doctor] so it only lasts a couple seconds . it does n't mean it's going to happen again . it's nothing bad . it will still work , so keep using it as long as you know you can stand it , okay ?
[patient] okay , thank you for explaining .
[doctor] so i will say , " apply to rash on face twice daily , until resolved . "
[patient] okay . so only apply to the rash area ?
[doctor] yes , and keep using the face wash.
[patient] okay .
[doctor] i think you could just do it once a day . i do n't think you need to do it twice a day , just because i do n't wan na dry your sky out too much , okay ?
[patient] i never noticed that my face is dry or got thin . i feel so good after using it .
[doctor] i understand , but it could get dry and i do n't wan na create other problems for you .
[patient] all right . i'll just wash once a day with it . but it was feeling very good , like there's this little bit of moisture getting back in . with the other wash , when i would use it twice a day , i was drying out . but not with this one .
[doctor] i see . okay . well then do what feels good . if you do notice that you're starting to get dry , then reduce to once per day .
[patient] that sounds good .
[doctor] so to review , um , continue using the same face wash , continue with metro cream , and increase the use of doxycycline to twice a day .
[patient] okay .
[doctor] and then just do it until it's gone , and then do it for once a day for another week before stopping .
[patient] okay , sounds good .
[doctor] all right . and i'll rewrite your instructions here .
[patient] thank you so much .
[doctor] if there are any other questions or you're getting different instructions , feel free to reach out to me and we'll clarify , okay ?
[patient] okay .
[doctor] but in general , doxycycline is such a low risk . we're not gon na have you on this forever . but especially since we're adding the tacrolimus , i expect it will clear quickly .
[patient] sounds good .
[doctor] all right . and i just wan na really help knock it out as fast as possible , since you've been dealing with it for so long now . i would take it twice a day until it's gone , and then once a day for a week before you stop . i'll write it out like that . so twice a day until rash is gone , and then once a day for another week before stopping .
[patient] okay .
[doctor] once the rash stops , you can stop the tacrolimus ointment . um , continue doxycycline another week and then stop . but you can keep using the wash and the metro cream .
[patient] okay , that sounds good . i can do that .
[doctor] and then hold off until i see you again before you start back any of your old products . um , if it's starting to flair again , um , if it's just a little bit , you can try just doing the tacrolimus for a couple days , to see if that's enough . if it's not , then restart the dy- doxycycline as well .
[patient] all right .
[doctor] i do n't expect that to happen , but , you know , if it does , you have the tools . um , then you'll be seeing me for a followup . we can figure out what to do next . i would say if it's getting worse rather than better , just give me a call or send me a mychart message , okay ?
[patient] yeah , sounds good .
[doctor] do you have enough refills ?
[patient] yeah , i think so .
[doctor] okay . so it looks like you have another refill of the doxycycline , so you're good there . metro cream , you probably still have enough of that one .
[patient] yes , i do .
[doctor] all right . and i'll cancel the elidel cream , just so we do n't complicate your list . uh , you have plenty of the face wash still .
[patient] yes .
[doctor] okay . uh , and we'll get rid of the clindamycin from your list as well .
[patient] and what would you suggest for a moisturizer ?
[doctor] yeah , so for that i would do something really basic like vanicream . or even , if it's just really dry , you could use a little bit of petroleum jelly . um , i'll give you a couple samples , okay ? let's make sure we have a followup in about four weeks .
[patient] okay , thank you .
[doctor] okay . and i would stay away from any kind of anti-aging thing , any kind of plant thing . um , really let's just be sure we talk about any new products , or reach out to me if you're gon na try something else . um , let's go get those samples .
[patient] okay , that sounds good .
[doctor] for assessment and plan , perioral dermatitis , rosacea , including ocular rosacea , and copy and paste her patient instructions . i recommend that she gently wash her eyelids once a day with gentle cleanser such as vanicream , also use bruder mask as needed .

CHIEF COMPLAINT

Follow-up for perioral dermatitis.

HISTORY OF PRESENT ILLNESS

Jacqueline Miller is a 40-year-old female who is being seen today for a follow-up skin exam for perioral dermatitis. She also has a history of rosacea, including ocular rosacea. Today, she states that her perioral dermatitis is well-controlled, although it has not fully resolved. The patient was applying doxycycline twice a day with improvement, but her pharmacist advised her to reduce to once daily since it had started to improve; therefore, for approximately the past week, she has been using the doxycycline only once per day. She has not seen continued improvement but it has not worsened. She is using the sulfacetamide wash twice daily, denies drying of the skin, and reports that her skin is much improved moisturization. She also applies MetroCream immediately after using the sulfacetamide wash. She denies using other lotions and products, Cetaphil lotion or soap, or Neutrogena wipes. The patient did not begin Elidel because it is not covered by her insurance, and she was concerned about possible side effects from the medication.

PAST HISTORY

Medical
Perioral dermatitis.

CURRENT MEDICATIONS

Doxycycline cream. Apply twice daily.
MetroCream.
Sulfacetamide wash. Apply topically twice daily.

PHYSICAL EXAM

Integumentary
Skin inspection of the face was performed today. On bilateral medial cheeks, there are a few, very faint, erythematous papules with mild redness around and underneath the nostrils. Fitzpatrick skin type is 4 to 5.

ASSESSMENT

• Perioral dermatitis
• Rosacea, including ocular rosacea

Jacqueline Miller is a 40-year-old female who presented today for follow-up for her perioral dermatitis, which has improved but not resolved. She decreased her doxycycline per her pharmacist’s recommendation, which possibly stagnated the resolution of symptoms.

PLAN

Perioral dermatitis.
I counseled the patient about the risks and benefits of doxycycline and recommended she resume twice daily application until she reaches full resolution, and at that point she should reduce application to once a day for an additional week. The patient will not be using Elidel as I reviewed the cost of the medication and without insurance, it was too expensive. I provided a prescription for Tacrolimus and counseled her on possible side effects of using the medication. She will continue with Sulfacetamide face wash once a day. Also, use Bruder mask as needed.

Rosacea, including ocular rosacea.
Continue using MetroCream twice daily. I recommended to gently wash her eyelids once daily with a gentle cleanser and try a gentle cream such as Vanicream.

INSTRUCTIONS

Call the clinic if symptoms worsen. The patient will have a follow-up appointment in 4 weeks.


[doctor] hey good morning bobby how are you
[patient] i'm doing okay i as you're aware doctor miller sent me over for this pain in my belly that i've had for several weeks they did he did an ultrasound and and said i had gallstones and they recommended i stay several way from some high fat food but i'm just still having a lot of pain and he referred me to you
[doctor] alright well i'm i'm sorry to hear that you're having pain but i i'm glad that he sent you over to see me i wan na talk a little bit more about that pain can you describe the kind of pain that you feel
[patient] well it's it's on the right hand side of my belly it's it's right underneath my ribs and it feels like a a squeezing severe pain it comes and goes but when it comes it's really severe and i get kind of nauseated and sick in my stomach
[doctor] okay and then when you get that pain can you rate that pain for me on a scale like zero being none ten being the worst pain you've ever been in your life
[patient] when it's severe it's it's probably an eight
[doctor] okay alright and then time wise are we looking at can it just come and go anytime or is it specifically around mealtimes how how does that pain kinda wax and wane for you
[patient] most of the time it comes right after i eat
[doctor] okay
[patient] but it also can come on a couple of hours after i eat also so it's either immediately after i eat or a couple hours later but it's related to eating
[doctor] okay
[patient] you know i like to eat right
[doctor] do n't weigh all so speaking of eating let's talk a little bit about your diet i see here on your chart that you're a type two diabetic and it looked like that you were gon na handle that with diet and exercise let's talk about that a little bit
[patient] well you know i my my diet was worse when i before i was diagnosed with the the type two diabetes
[doctor] okay
[patient] and since then i've cut back on sugar and i started a little bit of a keto diet and i've lost about twenty five pounds over the last three months
[doctor] okay so other than the weight loss how how is your diet is that has that been working out for you i mean do you does does that does that fit your lifestyle pretty well
[patient] yeah it does it does it it i was surprised it was n't as hard as i thought to go back and cut back and go more of a keto diet
[doctor] okay
[patient] but you know trying to cut out all those carbs my symptoms got better
[doctor] yeah
[patient] with the diabetes and my my blood sugars are improving but i still get that pain underneath the ribs
[doctor] yeah and that can happen and one of those things that causes that is that those intake of that fatty foods which is you know kind of the the keystone or the hallmark of the keto diet and have you noticed any improvement when you do cut out that fatty food and has that been difficult since you are watching your carb intake
[patient] the fatty food it is a little bit difficult you know i like those pork grinds and you know i i've had to kind of cut those out they were a nice staple for me when i was on the keto diet but i have cut out the those pork rinses because those were just so delicious and you know i would say it's a little bit better but i still get that pain
[doctor] okay and then do you have any family history of gallbladder disease
[patient] yeah but you know you know i knew that was coming both my dad and my mother both had gallbladder disease and had to have their gallbladders off
[doctor] okay so both both your parents your mom and your dad had your had their gallbladders taken out
[patient] yeah
[doctor] okay and then i wan na talk a little bit about your activity level and your and and if you're exercising has this affected your ability to to get out and exercise
[patient] not really i mean i usually i got ta watch it around meals you know but i've never been a big exerciser right after eating anyhow but you know i'm i'm so glad springs here because it gives me that opportunity to get back out and you know i love photography i i love nature of photography and with the with the the woods going from you know that dark barron look to coming alive with that green and and butting i i love to get out and take foot photographs there
[doctor] that's awesome to hear yeah i my wife and i like to go over and take nature hikes through the new park behind the rex center that just opened up have you ever been over there to do any any picture taken we've got a bunch of beautiful nature pictures that we took about a week ago
[patient] no i have n't been there i might have to try that out yeah
[doctor] yeah it's awesome
[patient] i like to get down near the river that's where i i like to catch especially around spring time
[doctor] that's great yeah next time you come in maybe you can bring in some of your pictures that'd be awesome to see
[patient] okay cool
[doctor] so i'm just curious talking about your symptoms here have you had any fevers you mentioned something about nausea but have you actually vomited from those symptoms
[patient] there's times when the pain is really bad for a couple of days i've had some what i i would describe as low grade fevers and yes you're right i have feel nauseated but i have n't thrown up
[doctor] okay so if it's okay with you i'm gon na go ahead and do a quick physical exam your vital signs look good today blood pressure was one twenty eight over eighty eight respiratory rate was sixteen your pulse rate was sixty eight you were afebrile today which is a good thing and your oxygen saturation on room air was ninety nine percent taking a listen to your heart here your heart is regular of rate and rhythm no i do n't hear any ectopic beats no clicks rubs or murmurs noted listening to your lungs here they are clear and equal bilaterally to auscultation now i'm gon na go ahead and do an an abdominal exam i do note positive bowel sounds soft nondistended abdomen however you are positive for some slight guarding there to the right upper quadrant but i do n't note any rebound tenderness now i'm gon na press slightly here beneath your ribs on the right hand side now take a breath in does that hurt when i press
[doctor] so i i see that you're guarded there so i'm gon na say that that it did hurt when i it did hurt when i
[patient] absolutely that hurts so much when you push right there
[doctor] okay
[patient] sorry i was just trying to capture capture my breath
[doctor] okay that's that's no problem so you are positive for murphy's signs but i do n't appreciate any peritoneal signs so let's talk a little bit about your results that i reviewed before you came in today so your abdominal ultrasound shows multiple gallstones present in the gallbladder and i do appreciate some mild thickening now the common bile duct size is within normal limits at four . one millimeters now let's talk a little bit about my assessment and plan for you okay i do believe you have some mild cholecystitis with gallstones i do n't appreciate any frank obstruction but it looks like your gallbladder is inflamed and it looks like that's happened maybe over the last few weeks since you've been having those symptoms now since you have n't had any improvement with dietary modifications i am going to make the recommendation that we do remove your gallbladder and i would like to perform a laparoscopic cholecystectomy now what that means is i'll make a few small incisions and insert a scope with some of those instruments that's gon na remove that gallbladder through one of those little bitty incisions now the surgery is gon na take about an hour to an hour and a half and you'll probably spend the night in the hospital because we just wan na monitor you post procedure to make sure everything is okay you're still gon na wan na avoid those high fat foods after surgery and eat foods that are gon na be high in fiber now do you have any questions about what our assessment and plan is for for this
[patient] no no questions today
[doctor] okay now the other thing
[patient] how soon can i how soon will i be able to get up and get moving back outside after the surgery
[doctor] so the good news is since it's a laparoscopic procedure you're gon na be back on your feet pretty quick now for the first twenty four hours i'm gon na want you to take it pretty easy but after a couple of days if you feel like moving around on some solid ground you know we do n't want you hiking or anything like that but if you feel like moving around on some solid ground you can get up and walk around within a day or two and then in about a week or so i'll see you again and then we'll release you to go get back out there in nature
[patient] okay thank you very much
[doctor] you're very welcome the other thing i wan na talk briefly about is now your not your type two diabetes i want you to follow up with your physician just to make sure that you're handling your diabetes especially the fact that you're gon na have surgery and those type of things and we will just continue to monitor your diabetes as has been outlined by your your additional either your endocrinologist or your primary care provider i'm gon na have the nurse come in and get some paperwork signed and if you do n't have any questions for me i will see you next week and we will get this gallbladder out
[patient] well thank you very much i'm looking forward to i i do n't want anymore of that pain so
[doctor] alright that sounds good we'll see you next week then
[patient] okay take care
[doctor] yeah

CHIEF COMPLAINT

Abdominal pain.

MEDICAL HISTORY

Patient reports history of type 2 diabetes.

SOCIAL HISTORY

Patient reports enjoying nature photography.

FAMILY HISTORY

Patient reports family history of cholelithiasis. Both of his parents have had cholecystectomies.

REVIEW OF SYSTEMS

Constitutional: Reports low-grade fevers.
Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting.

VITALS

Blood Pressure: 128/88 mmHg.
Respiratory Rate: 16 breaths per minute.
Heart Rate: 68 beats per minute.
Oxygen Saturation: 99% on room air.
Body Temperature: Afebrile.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear and equal bilaterally.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No ectopic beats. No murmurs, clicks, or rubs.

Gastrointestinal
- Examination of Abdomen: Soft, nondistended abdomen. Positive slight guarding to the right upper quadrant, but without rebound tenderness. Positive for Murphy signs. Peritoneal signs not appreciated.
- Auscultation: Bowel sounds normal in all 4 quadrants.

RESULTS

Abdominal ultrasound obtained at an outside facility is reviewed today. This demonstrates multiple gallstones present in the gallbladder. I do appreciate some mild thickening. The common bile duct size is within normal limits at 4.1 mm.

ASSESSMENT AND PLAN

1. Mild cholecystitis with gallstones.
- Medical Reasoning: Based on the patient's symptoms, exam findings, and ultrasound, I do believe he has some mild cholecystitis with gallstones. I do not appreciate any frank obstruction, but it looks like his gallbladder is inflamed. This appears to have happened maybe over the last few weeks or since he has been symptomatic.
- Patient Education and Counseling: I had a thorough discussion with the patient concerning surgical treatment. The preoperative, intraoperative, and postoperative courses of care were described and discussed. I explained the surgery will take approximately 1 to 1.5 hours, and he will probably spend the night in the hospital for post-procedure monitoring. We also discussed that he should avoid high fat foods after surgery and eat foods that are high in fiber. All questions were answered.
- Medical Treatment: Since he has not had any improvement with dietary modifications, I recommend a laparoscopic cholecystectomy. A mutually agreed upon surgical date has been scheduled for 1 week.

2. Type 2 diabetes.
- Medical Reasoning: The patient is currently managing his diabetes with diet and exercise.
- Patient Education and Counseling: I advised the patient he should refrain from hiking in the immediate postoperative period; however, he may return to walking outdoors on solid ground 1 week status post-surgery.
Medical Treatment: I recommended he follow up with his physician regarding his impending surgery. We will continue to monitor his diabetes as has been outlined by either his endocrinologist or his primary care provider.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

INSTRUCTIONS

The patient will follow up with me 1 week status post-surgery.


[doctor] hi matthew how are you the medical assistant told me that you injured your shoulder
[patient] hey yeah i'm i'm hanging in there
[doctor] what happened
[patient] yeah so well when i was younger i used to be a little bit more active with my friends with the playing
[doctor] pick up football and so you know me being a little bit older now i thought i'll take back up with no problem well i did i tried and all the other guys were a little bit bigger than me so i got i got tackled a couple of times and it just
[patient] i kinda landed on my shoulder a little bit weird one time and so like i got back into the game i was okay but yeah ever since then the past couple of days it's just been it's been really bothering me
[doctor] okay alright and so when exactly did this happen
[patient] yeah i'd say maybe it was probably about last weekends so i'd say about like four days ago
[doctor] okay well i'm happy at age 67 you're out there playing tackle football so good good for you and was it your right shoulder or your left shoulder that you injured
[patient] it was my right
[doctor] okay and are you right or left handed
[patient] i'm right handed
[doctor] okay and have you had any numbing or tingling in your fingers at all
[patient] no fingers have been okay
[doctor] okay and any problems with the strength of the arm at all are you able to grab a cup of coffee
[patient] yeah i hand's doing okay i can grab yeah i'm just trying to avoid lifting anything yeah anything anything anything a little bit too heavy like i had a chipment command so i had a box in the driveway the other day and reaching down and picking up the box was a little tough
[doctor] okay and where exactly on your shoulder does it hurt
[patient] yeah it's kinda on the on the back side right right around here
[doctor] mm-hmm okay alright and are you able to lift up your shoulder so that your shoulder touches your ear at all
[patient] yeah no that's that's that's hurting a little bit
[doctor] okay alright and what have you taken for the pain
[patient] just a little bit of tylenol trying to take it easy
[doctor] did that help at all
[patient] it it kinda like kept it at the same spot that has been but it really did n't make it go down
[doctor] okay so are your symptoms any better since it happened or they about the same
[patient] no they are about the same
[doctor] okay and any neck problems did you injure your neck when this happened
[patient] no neck has been okay
[doctor] okay and any other joint problems like does your elbow hurt on that side or your wrist or is it just your shoulder
[patient] nope the the rest of it's doing okay it's just the just the shoulder
[doctor] okay and any other orthopedic injuries in the past have you ever injured that shoulder before as far as you know
[patient] nope nope that one that one's been fine
[doctor] okay and any any other surgeries or any other medical problems
[patient] i mean i had a appendicitis so i had an appendectomy
[doctor] okay
[patient] maybe like three four years ago but that's about it
[doctor] okay alright well i'm just gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so and last thing have you had any fever or chills since this happened at all
[patient] a slight headache but no no no fever
[doctor] okay did you hit your head when you when this happened
[patient] a little bit
[doctor] okay alright did you pass out
[patient] nope nope stayed conscious throughout
[doctor] okay alright well looking at your vital signs here in the office you do n't have any fever your blood pressure looks quite good it's about one twenty two over seventy six your heart rate is appropriate at eighty two beats per minute and your oxygenation is ninety five percent on room air on your cervical spine exam there is no tenderness to palpation of the cervical spine there is full range of motion on head exam there does not appear to be any trauma there is no ecchymosis or bruising on the right shoulder exam on your musculoskeletal exam there is pain to palpation of the posterior shoulder at the acromioclavicular joint there is decreased abduction and adduction to about ninety degrees only there is there is a he has pain with supination and pronation of the right arm and there is a palpable radial radial artery pulse okay so what does that mean that just means that you have some you know evidence of the injury there and we'll we're gon na talk about that so i had the nurse do a shoulder x-ray on you before i came in the room and the results of your right shoulder x-ray showed that you have an acute acromioclavicular joint fracture so you just have a a a small fracture of the acromion i do n't think that it it's gon na be anything that we need to do surgery for so let's just talk a little bit about my assessment and plan so for your right shoulder injury for your acute acromioclavicular joint fracture i wan na go ahead and just put you in a sling for now i wan na go ahead and prescribe meloxicam fifteen milligrams once a day i wan na go ahead and just order a cat scan of your right shoulder just to kinda get a better look of how the joint looks and we're gon na go ahead and refer you to physical therapy to strengthen your shoulder in hopes of avoiding surgery in the future how does that sound
[patient] yeah that that sounds great just being able to take a little bit of something for the pain would would would be really appreciated
[doctor] okay do you think you need something stronger than meloxicam
[patient] no i'll give that a shot
[doctor] okay
[patient] and see how that goes
[doctor] okay any questions
[patient] when can i get back out on the field
[doctor] well you ca n't play taggle football for a while you have to have this fracture healed
[patient] okay
[doctor] and i would avoid doing it you know as we get older you know our bones get a little bit weaker so i would avoid the tackle football maybe flag football in the future okay
[patient] yeah yeah that sounds good
[doctor] okay anything else
[patient] no i think that's that's been great thank you so much
[doctor] okay you're welcome have a good day bye
[patient] thanks

CHIEF COMPLAINT

Right shoulder injury.

HISTORY OF PRESENT ILLNESS

Matthew Allen is a 67-year-old male, right-hand-dominant, male who presents to the clinic today for the evaluation of a right shoulder injury. The patient sustained this injury 4 days ago, when he was tackled a couple of times playing pick up football and landed on his right shoulder. He states that he was able to return to the game, however he has had pain since that time. The patient locates his pain to the posterior aspect of his shoulder. He denies any numbness or tingling in his fingers. He states that the strength in his hand is okay; however, he has been trying to avoid lifting anything too heavy. Mr. Allen denies being able to touch his shoulder to his ear because of pain. The patient has been taking Tylenol for pain, which does not provide relief. He denies any neck problems or other joint problems. The patient denies any previous orthopedic injuries to his right shoulder. He denies any fever or chills since the injury, but does note a headache. The patient states that he hit his head at the time of the injury but did not pass out.

SURGICAL HISTORY

The patient has a history of an appendectomy 3 to 4 years ago.

REVIEW OF SYSTEMS

Constitutional: Denies fever or chills.
Musculoskeletal: Reports right shoulder pain. Denies neck pain.
Neurological: Reports headache. Denies numbness or tingling.

VITALS

BP: 122/76.
HR: 82 bpm.
SpO2: 95% on room air.

PHYSICAL EXAM

NECK: Examination of the cervical spine reveals no tenderness to palpation. Full ROM.
HEAD: There does not appear to be any trauma. No ecchymosis or bruising.
MSK: Examination of the right shoulder reveals pain to palpation of the posterior shoulder at the acromioclavicular joint. There is decreased abduction and adduction to about 90 degrees only. Pain with supination and pronation of the right arm. Palpable radial artery pulse.

RESULTS

X-ray of the right shoulder reveals an acute acromioclavicular joint fracture.

ASSESSMENT

Right shoulder acute acromioclavicular joint fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays revealed an acute acromioclavicular joint fracture. The plan is to place the patient in a sling and prescribe meloxicam 15 mg once a day to treat his pain. I also recommend that we obtain a CT scan of the right shoulder to evaluate further. I recommend that the patient attend formal physical therapy to strengthen his right shoulder in hopes of avoiding surgery in the future. In the meantime, I have advised him to avoid tackle football.


[doctor] hi jeremy how are you the medical assistant told me that you injured your back
[patient] yeah i was moving some boxes when my son was moving out of his college dorm and i really hurt my lower back
[doctor] okay how long ago did that happen
[patient] this was about four months ago
[doctor] about four months ago okay that's quite a long time and you're just seeing me now for it
[patient] yeah the appointments were backed up and i tried some pt at my gym but it it really did n't seem to help and i was really concerned
[doctor] okay and what exactly are your symptoms are you having pain when you're just sitting there or when you're moving around for a very short period of time it felt like i was gon na tapple over i like i could n't support my my upper body weight and then my right toe or the the toes on my right foot tingled a little bit but that went away after about an hour okay are you still getting that numbing and tingling periodically in your feet or is that completely gone
[patient] that's completely gone it it just happened when i first felt the the tweak in my lower back i felt that sensation but i have n't since
[doctor] okay and how about any difficulty or weakness in your legs
[patient] only if i'm carrying something heavy otherwise it seems relatively normal but i i feel the sensation so i'm a little nervous about carrying something heavy
[doctor] okay and are and do you still have pain down there in your lower back if i turn a certain way or if i roll over in my sleep i'll wake up from it from a like a sharp pain but then that that goes away if i if i position myself the right way okay and what have you been taking for the pain
[patient] i took some tylenol i took some ibuprofen i've tried heat i've tried ice and nothing really seems to help
[doctor] okay is the ibuprofen any better than the tylenol
[patient] a little bit but for sure a shorter period of time
[doctor] okay and did you get any stomach upset from the ibuprofen
[patient] no i try not to take too much so i i do n't have an upset stomach from it
[doctor] okay and did you go to like an urgent care centing or an emergency room have you had any imaging on this at all
[patient] i went to an urgent care and they wanted me to do an mri but i was a little concerned because i think we maxed out our insurance so i i did n't do it because it started to feel better but because it's been going on so long i'm i'm a little bit concerned now i i do wan na actually move forward with that
[doctor] okay alright and any other symptoms any problems with like your bladder or your bowels any incontinence or you know you feel like you ca n't go to the bathroom
[patient] no i have n't had any of those issues
[doctor] okay alright and any other any other past medical history do you that you have any
[patient] i had knee surgery about two years ago on my right knee
[doctor] okay
[patient] that went fine i rehabbed it pt has been fine it it feels about ninety five percent ever since
[doctor] okay and what did you have done to your right knee
[patient] it was a total knee replacement
[doctor] okay a total knee replacement in twenty eighteen is that what you said
[patient] no it was actually about two years ago so it's the spring of twenty twenty
[doctor] okay alright alright well i wan na go ahead and just move on to a physical exam i'm gon na be calling out some of my exam findings
[patient] mm-hmm
[doctor] now you have you had any fever or chills with this
[patient] no
[doctor] okay alright alright so looking at your vital signs here in the office you know they look really good your you you do n't have any temperature your blood pressure is good it's about one seventeen over fifty six
[patient] mm-hmm
[doctor] your heart rate is nice and slow at sixty eight and your oxygenation is fine at ninety five percent on room air so that means everything looks good
[patient] good
[doctor] on your neck exam i i do appreciate some bony protuberance of the c5 c6 do you have any pain when i touch here
[patient] no
[doctor] no okay on your lumbar spine exam i do appreciate do you have pain when i touch here
[patient] no
[doctor] okay so there is no pain to palpation of the lumbar spine there is decreased flexion and extension of the lower back the patient does have a positive straight leg raise and there is some spasm of the paraspinal muscles of the lumbar spine on musculoskeletal exam the lower extremities strength is equal bilaterally so what does that mean jeremy that means that you have some you know maybe a some arthritis in your neck here and or maybe just a a little bit of some injury from from that from that back that back thing that you told me about
[patient] mm-hmm
[doctor] okay but i think overall things look really good so you know i had them do an lumbar spine x-ray on you before i saw you and i looked at the results of your lumbar spine x-ray which showed no acute bony abnormality you know there was no fracture of your back or anything which is not surprising based on your history so let's just talk a little bit about my assessment and plan so i do believe it sounds like you have an acute disk herniation now this did happen a few months ago but it sounds like that's what you had based on the fact that you're still having symptoms
[patient] mm-hmm
[doctor] i do wan na go ahead and order a a lumbar spine mri to get a a a better look at what's going on you know x-rays really just look at the bones they do n't show us any of the soft tissue so let's go ahead and order the lumbar spine mri i wan na continue with physical therapy so i'm going to refer you to a a physical therapist through our health system
[patient] mm-hmm
[doctor] and then i also wan na go ahead and prescribe meloxicam fifteen milligrams once a day
[patient] mm-hmm
[doctor] to help with that do you have any questions about that
[patient] no questions
[doctor] now if you do have a herniated disk we can go ahead and talk about some other treatment options maybe like an epidural steroid injection to help take down some of that inflammation
[patient] mm-hmm
[doctor] it might make you feel better but we'll we'll deal with that when we get get there okay
[patient] sure
[doctor] any questions
[patient] not at this point
[doctor] okay great thank you
[patient] thank you

HISTORY OF PRESENT ILLNESS

Jeremy Adams is a pleasant 57-year-old male who presents to the clinic today for the evaluation of low back pain. The onset of his pain began 4 months ago, when he was moving boxes out of his son’s college dorm. At that time, he noted tingling in his right toes, which resolved after approximately 1 hour. After his injury, he felt as though he was unable to support his upper body weight. The patient reports weakness in his legs when carrying heavy objects. He reports a sharp pain in his lower back when he turns a certain way or rolls over in his sleep. The pain will resolve with repositioning. The patient was seen at urgent care and was referred to obtain an MRI, however he did not undergo this secondary to insurance issues. He has been utilizing Tylenol, ibuprofen, heat, and ice for pain, which does not provide relief. The patient notes the ibuprofen is slightly more beneficial than the Tylenol, however it does not relieve his symptoms. He denies upset stomach with the use of ibuprofen. Additionally, he attempted physical therapy at his gym without any relief. He denies any bladder or bowels issues, fevers, and chills.

SURGICAL HISTORY

The patient has a history of a right total knee arthroplasty 2 years ago, in spring of 2020. He states that his right knee feels 95% improved since the surgery.

REVIEW OF SYSTEMS

Constitutional: Denies fevers or chills.
Gastrointestinal: Denies bowel issues.
Genitourinary: Denies bladder issues.
Musculoskeletal: Reports lower back pain.

VITALS

Temperature: Normal.
Blood pressure: 117/56 mm Hg.
Heart rate: 68 BPM.
Oxygenation: 95% on room air.

PHYSICAL EXAM

NECK: Bony protuberance of the C5-C6. No pain to palpation of the C5-C6
MSK: Examination of the Lumbar spine: No pain to palpation of the lumbar spine. Decreased flexion and extension of the lower back. Positive straight leg raise. Spasm of the paraspinal muscles of the lumbar spine. Strength is equal bilaterally.

RESULTS

X-rays of the lumbar spine were reviewed. These reveal no acute bony abnormalities.

ASSESSMENT

Low back pain, possible acute disc herniation.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. His x-rays did not reveal any signs of a fracture. I would like to obtain an MRI of the lumbar spine to evaluate for a possible acute disc herniation. I have prescribed the patient meloxicam 15 mg to treat his pain. He will continue with physical therapy and a referral was provided for this today.


[doctor] so dennis is a 57 -year-old male today complaining of shortness of breath he has also got a history of diabetes high blood pressure and history of asthma so dennis tell me what's going on how're you doing
[patient] not too good
[doctor] okay how long have you been feeling not too well
[patient] about a couple of weeks
[doctor] couple of weeks tell me what's going on
[patient] i wake up with shortness of breath
[doctor] okay
[patient] i go to when i'm short of breath there i get back home and i'm again short of breath so i had a tough time dealing with this
[doctor] have you noticed any are you coughing up anything any swelling in your legs or what's going on
[patient] yeah i've been i've been coughing up i've been coughing up blood
[doctor] okay how long has that been going on for
[patient] probably three weeks or so
[doctor] okay and are you coughing a lot of blood or just a little bit of blood
[patient] i shave three to four cups a day
[doctor] wow that's a lot of blood okay are you throwing up any blood are you having bleeding in any place else or just when you cough
[patient] only when i cough
[doctor] okay have you noticed any bruising or bleeding from your teeth or anything like that or from your gums or anything like that
[patient] no
[doctor] okay any leg swelling or calf swelling or any any anything like that any recent travel history you've been on a plane or trip recently
[patient] i had some knee problem but there is no swelling but it hurts that's been going on for quite some time
[doctor] okay so that's not near the knee problem okay and have you had any have you been to the hospital or been to the emergency room or anything like that for your coughing and coughing up blood
[patient] no i tried to get an appointment in the office but they were kinda booked up
[doctor] okay
[patient] they just numb
[doctor] alright and alright no but no fevers with this so since you're here your oxygen level looks pretty good in the clinic it's about ninety four percent on pulse your pulse oxygenation so that's good are you short of breath so when you walk or you or you exert yourself you're short of breath you said right okay and have you and how how is your blood sugar been doing since this has been going on i know you're on metformin how's your diabetes been doing
[patient] not so good you know it kinda going up and down i wear this dexcom
[doctor] okay
[patient] you know after meal they spike up well over two hundred
[doctor] okay and
[patient] and morning when i get up they are around one fifty
[doctor] okay alright so it's been running a little bit high i know we checked your hemoglobin a1c last time and it was about seven . seven . i think and we had talked about you know improving your diet and improving some exercise but is this blood sugar been high and low or high and normal when you're especially in the last three weeks or has it been going on for longer than that
[patient] i would say about a month
[doctor] okay alright and how is your blood pressure been at home since you've been taking since these episodes that you've been sick are you taking norvasc
[patient] yes i am but i keep them on some days because my blood pressure has been running somewhat on the low side
[doctor] okay alright and right now it's about a hundred and twenty over seventy what how low does it go in the more when you check it
[patient] well there are sometimes in the lower nineties
[doctor] okay alright well let me let me examine you here in a second and we'll think about you know what we need to do especially with your coughing and your shortness of breath okay so nita i'm i'm examining you now let's pretend i did my exam i'm just gon na verbalize some of my findings so i can put it into my chart okay and i'll explain what those things mean so on my exam you've got no jvd there is no swelling in your neck no carotid bruits your lung exam you've got some rails and some rhonchi on on more on the right side i do n't hear any wheezing right now there is some diminished breath sounds in the right side as well on your heart exam you've got two over successolic ejection murmur you've had that in the past that's unchanged from before the rest regular rate and rhythm otherwise your belly exam is nice and soft on your extremity exam you've got one plus nonpitting edema on both of your lower extremities on your on your ankles no calf tenderness no negative homan sign so what does all this mean so basically you've got you know you've got some sort of infection or something going on in your lungs that i can hear right now the rest of your exam is pretty much stable it's unchanged from before so let's talk about what we what we should do about this so for the for the first problem with the shortness of breath the first thing i wan na do is go ahead and get a chest x-ray for you okay you've been coughing up blood i also wan na send you to the emergency department to get some blood testing done i'm worried about a blood clot or something else going on so i wan na get a cat scan of your chest as well so i'm gon na go ahead and refer you to the emergency department i'll call them and and have you head over that way they can get a chest x-ray and a cat scan and some blood work as well and then we'll evaluate why you're having the shortness of breath and why you're coughing up this blood okay and then depending on what they find you may need you know it could be as simple as a pneumonia or it could be something a little bit more serious we may have to get you know start you know depending on what you find we will get the right treatment started any questions about that or can you drive to the emergency department from here or is that okay
[patient] yeah i can bike no problem i have no question
[doctor] alright for the second problem for the diabetes since your blood sugar is running a little bit high once you get over this i'm blood sugars running a little bit high once we get you over this hump of the shortness of breath and get this diagnosed i'm gon na go ahead and order another hemoglobin a1c today we will probably increase your dose of metformin from five hundred twice a day to seven fifty twice a day so why do n't we do that and then why do n't we have we'll have the hemoglobin a1c back and then we can once you get over this illness that you're undergoing we'll we'll we'll discuss that more i'll have you come back in about three weeks to just discuss your diabetes and what our treatment plan will be for that okay
[patient] okay
[doctor] for the high blood pressure definitely hold off on the norvasc for right now let's figure out what's going what's causing this episode of shortness of breath i want some blood testing done and and once we have that under better control we can reassess your blood pressure so right now hold the norvasc and then we'll have you come back once everything is done okay
[patient] no
[doctor] any other questions or anything we know if we need to talk about today
[patient] no i'm good
[doctor] sounds good we'll get you signed out here in a second

CHIEF COMPLAINT

Shortness of breath with hemoptysis.

MEDICAL HISTORY

Patient reports history of diabetes, hypertension, and asthma. He also has a long history of knee pain.

MEDICATIONS

Patient reports taking metformin and Norvasc.

REVIEW OF SYSTEMS

Constitutional: Denies fever.
HENT: Denies bleeding gums.
Respiratory: Reports shortness of breath, hemoptysis.
Musculoskeletal: Reports knee pain. Denies lower extremity edema.
Hematologic/Lymphatic: Denies bruising.

VITALS

Pulse oxygenation: 94 percent. Blood pressure: 120/70 mm Hg.

PHYSICAL EXAM

Neck
- General Examination: Neck is supple. No JVD. No carotid bruits.

Respiratory
- Auscultation of Lungs: Some rales and rhonchi, more on the right. No wheezing right now. There is some diminished breath sounds in the right as well.

Cardiovascular
- Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur, unchanged from before.

Gastrointestinal
- Examination of Abdomen: Soft.

Musculoskeletal
- Examination: 1+ nonpitting edema on bilateral lower extremities. No calf tenderness. Negative Homan's sign.

Hematology/Lymphatic/Immunology
- Examination: No bruising.

ASSESSMENT AND PLAN

1. Shortness of breath.
- Medical Reasoning: The patient has been coughing up blood.
- Patient Education and Counseling: We discussed the importance of further testing as his symptoms could be as simple as a pneumonia or something more serious.
- Medical Treatment: I have ordered a chest x-ray, CT scan, and blood work to be done in the ER. I have instructed the patient to go into the ER immediately after this appointment and I will call ahead.

2. Diabetes.
- Medical Reasoning: The patient's blood sugar has not been well controlled.
- Medical Treatment: I have ordered an updated A1c today. He will increase his metformin to 750 mg twice daily.

3. Hypertension.
- Medical Reasoning: His blood pressure has been running low for approximately 3 weeks. I believe this could be caused by his shortness of breath. I would like to get a better understanding of the cause of his shortness of breath prior to pursuing further treatment for his hypertension.
- Medical Treatment: At this time, he will discontinue the use of Norvasc.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

INSTRUCTIONS

We will have him follow up in about 3 weeks to just discuss his diabetes and further treatment recommendations.


[doctor] alright scott so so i understand that you you had some right knee injury can you tell me a little bit about what happened
[patient] yeah i was trying to go out and play some pickup soccer games over the weekend and went to go plank kick the ball and and just felt a pop in my right knee
[doctor] okay and and how long ago did that happen
[patient] about three days ago
[doctor] three days okay and when did you notice any swelling anything like that
[patient] it it's swollen some some of that swelling has gone down
[doctor] okay
[patient] but it it mainly just it it feels like that i just i ca n't my knee is just not as functionally it's not moving as well as what it used to be it seems to be a little limited
[doctor] okay alright and then so how's the pain with your knee on a scale of one to ten one being the least pain ten being the worst pain how's how's it been ranging
[patient] it's somewhere between six and seven right now it's about four or five with some of the swelling going down
[doctor] okay alright and did you take anything at all to relieve the pain
[patient] anti-inflammatories
[doctor] okay alrighty and did that help
[patient] yeah the ibuprofen helped a little bit but i'm on it pretty on a pretty regular basis right now
[doctor] gotcha okay now tell me are you able to bend or straighten your leg ever since then
[patient] i can bend it but it hurts towards the end of the motion and i can straighten it but it does n't it feels like i have to help get it straightened
[doctor] okay alright and then how about you able to bear any weight on it or walk on it at all
[patient] i can still bear weight on it but it feels just really loose it it does n't feel normal
[doctor] gotcha okay alright well let's go ahead and take a look at your knee here real quick before i take a look at your knee here i'm gon na do a physical exam and in terms of your gait here i did notice that you do have a marked limp on your looks like it's your right leg upon ambulation so let me go ahead and take a look at that right knee real quick i do appreciate some significant effusion in the right knee just a slight bit of ecchymosis let me just feel around here scott how does that feel does that hurt when i kinda press on that there
[patient] a little bit of pain there not not really bad it's it feels like it's just more on the inside of my knee
[doctor] yep okay so you definitely feeling some a little bit of pain to palpation at the medial joint line now i'm gon na have you lie on your back and also i'm gon na do some maneuvering here of your leg i'm gon na do a real quick test on you here okay alright how does that feel
[patient] just feels just feels loose it hurts when you pull it at the very end
[doctor] okay sorry about that alright so you're definitely having some difficulty with some passive range of motion here and you're lacking a few degrees of terminal extension to about a hundred and fifteen degrees as well as lacking about maybe twenty to thirty degrees of terminal flexion on the secondary secondary to the pain here and you do have a positive lachman exam so one more thing i wan na take a look at real quick i'm gon na take a look at your toes here real quick very good so neurovascularly your bilateral lower extremities are intact and it looks like you have a muscle strength of a five out of five so scott you know based on my examination here your right knee injury is really suggestive of anterior cruciate ligament tear and you've heard of it probably even heard as acl tear sometimes especially when a lot of people do sports and they injure their knee that that can happen so my plan for you though is i wan na i wan na go ahead and order an mri because i wan na evaluate the integrity of that acl now you may need surgery but we'll we'll first take a look at that mri result and reevaluate and reevaluate that first but in the meantime i wan na go ahead and order some anti-inflammatory medication meloxicam fifty milligrams a day it's gon na help reduce that swelling and the pain and then i want you to go ahead and ice the knee if you need to if you're still seeing some swelling and some pain you can go ahead and use ice as well but i definitely would like for you to moderate your activities so i would like for you to wear a knee immobilizer and then also use crutches when you walk around just to help you a little bit so not to put too much stress and strain on that knee does that sound like a plan
[patient] it it does now well i need to limit my work activities i i typically sit behind a desk but it's not been very comfortable sitting here lately
[doctor] yeah definitely so yeah so you you can limit the activities for sure in terms of your work activities i know if you sit too long sometimes it can be painful because you do need to move that leg a little bit so it does n't lock up so i i would like for you to you know do do some slight activities not enough to stress your legs but definitely move move them a little bit every now and then so it does n't lock up on you okay
[patient] okay
[doctor] alright i do want you to i know you are i know you actually jog often so i want you to just slow that down for a bit no jogging for a while until we get you know results of your mri till we figure out what we what we are gon na be doing okay
[patient] okay
[doctor] alright and how's your dog you has it been jogging with you before this incident
[patient] how's just how's my dog or how is my job
[doctor] your your dog
[patient] my my my dog is okay
[doctor] good
[patient] is doing really well and and he enjoys still playing around outside but looks like wo n't be able to do that for a little bit
[doctor] very good alright well i'm gon na go ahead and have the nurse take you to the scheduler to get your mri and i'll get back with you as soon as we get the results of that
[patient] okay sounds good thank you
[doctor] thank you

CHIEF COMPLAINT

Right knee injury.

HISTORY OF PRESENT ILLNESS

Scott Miller is a pleasant 36-year-old male who presents to the clinic today for the evaluation of a right knee injury. The injury occurred 3 days ago, when he was playing pickup soccer games and felt a pop in his right knee. He reports swelling at the time of the injury, which has improved. The patient states that his knee is not as functional or moving as well as it used to be. He rates his pain level as a 6 to 7 out of 10 currently and a 4 to 5 out of 10 when the swelling decreases. The patient has been taking ibuprofen on a regular basis, which provides some relief. He states that he is able to bend his knee with pain towards the end of this motion; however, when he goes to straighten his knee, he feels like he has to help it straight. The patient adds that he is able to bear weight on his right knee, however it feels loose and does not feel normal.

SOCIAL HISTORY

The patient works at a desk.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain.

PHYSICAL EXAM

GAIT: Marked limp in the right leg upon ambulation.
MSK: Examination of the right knee: Significant effusion. Slight ecchymosis. Pain with palpation at the medial joint line. Difficulty with passive ROM. Lacking a few degrees of terminal extension to 115 degrees. Lacking 20-30 degrees of terminal flexion secondary to pain. Positive Lachman's test. Muscle strength is 5/5. Neurovascular intact distally.

ASSESSMENT

Right knee pain, possible anterior cruciate ligament tear.

PLAN

After reviewing the patient's examination findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate the integrity of the ACL. I have prescribed the patient meloxicam 15 mg a day to reduce swelling and pain. We discussed that the patient should utilize ice and activity modification to reduce swelling and pain. I recommended that he wears a knee immobilizer and use crutches when he is ambulating. He will avoid jogging until we have the results of his MRI.

INSTRUCTIONS

The patient will follow up with me once the MRI results are available for review and further discussion.


[doctor] alright teresa i see here in your chart that you seem to be experiencing some elbow pain could you tell me where it hurts
[patient] yeah so it's hurting on the inside of my elbow
[doctor] mm-hmm
[patient] and when i i i've been doing some pottery i've been creating you know i have a pottery wheel and i've been i love my pottery and for my son's birthday i've been making a a ceramic bowl and i'm gon na paint it and i have to do some real full decorations but i've really been working on it a lot and my gosh this is hurting and i ca n't work on it right now because it's hurting so much
[doctor] i am so sorry so i mean that's really cool that you do parttery it's something that i've wanted to pick up you know but i do n't know that i have those skills yet does the pain radiate down your arm or up your shoulder or anything
[patient] yeah it does down my arm and along that inside of my arm
[doctor] okay so the medial aspect okay have you did you hit it on anything
[patient] no not that i recall
[doctor] okay and have you ever injured your elbow before
[patient] no i have n't
[doctor] okay alright so on a on a scale of one to ten with ten being your arm is actively being sought off by a chainsaw how bad is the pain
[patient] well i'd say it's about a seven
[doctor] wow that's pretty bad does it keep you up at night
[patient] yes it really does it's you know if i roll over and it it it just wakes me up
[doctor] okay have you done anything to relieve the pain
[patient] well i have been taking some ibuprofen but that is n't really helping
[doctor] okay and have you tried anything like ice or heat or anything else
[patient] i tried a little bit of ice at first
[doctor] mm-hmm
[patient] but and it's just it's been hurting for about four days now
[doctor] okay
[patient] did n't getting better
[doctor] okay okay so it's probably it do you think it's getting worse
[patient] well it's just not getting better
[doctor] okay no i understand okay so i know that you also have like a history of hypertension and that we have you on ten milligrams of lisinopril have you been checking your blood pressures regularly
[patient] yeah you know what i remember too i mean they they have been pretty good one teens to one thirties
[doctor] okay alright and okay do you think that you've been good about taking your medications do you usually take them everyday
[patient] yeah pretty much i i i you know set an alarm for that lisinopril
[doctor] awesome that's great alright and so i see that you also we are treating you for diabetes as well and that we have you on five hundred milligrams of metformin twice a day how about that have you been taking that regularly
[patient] well sometimes i forget i mean having a medication twice a day you know sometimes i'm out doing stuff and i just forget to take it
[doctor] okay
[patient] and plus i kinda have a sweet tooth so you know sometimes they're a little bit higher you know like one fifty to one seventy so
[doctor] okay alright so when you say a sweet tooth what are we talking about there
[patient] i love to bak also besides my ceramics i'm really big and baking and i like to make cakes and and take them to you know parties and get togethers you know family get togethers and i like to make senna rules too i've been doing that since i was very young so i kinda noticed that
[doctor] okay cinnamon rolls can be kind of hard like do you for your cakes do you do you use fondant you know to like do any of the decorations
[patient] no i i mine are just pretty basic they're not overly fancy
[doctor] okay
[patient] simpon rolls i got that recipe out of a southern living magazine
[doctor] oof
[patient] a long time ago and
[doctor] so you know it's good
[patient] yeah
[doctor] alright well so i totally understand like baking and like the excitement of being able to give those to your family but we maybe wan na start cutting down on eating and taste testing ourselves is do you think that's something we could manage
[patient] yeah i know i need to get better on it i probably could use maybe a refresher on just managing what i should and should n't eat how like if i need to combine a protein you know if i do eat something a little bit sweet maybe pling a protein or something with it
[doctor] mm-hmm yeah that sounds like a
[patient] had some friends tell me something about that
[doctor] yeah that sounds like a great idea and i think if that's something that we can maybe discuss to get you in contact with someone who can offer you someone with a degree that can offer you some really good advice you know i do n't wan na as much as it's really helpful to have friends i do wan na be able to give you like a source of truth right
[patient] yeah i i had a diabetic consult a long time ago but yeah it it would be nice to see a dietitian again and go over those and maybe there is some new stuff too
[doctor] a hundred percent yeah you know like i one of the things that i struggle with is like are eggs good for you or bad for you you know like with cholesterol i feel like it changes every other year or something like that so you're right there may be some pieces of information that we do need to update and and you know over a fresh of course would n't hurt but if you do n't mind i'm gon na go ahead and start my physical exam i'm gon na call out my findings and just go let me know if you have any questions or if anything sounds anything that you you want me to expand on further but this is just for the recording sake so we can get everything documented okay
[patient] yeah and can i ask you what word what were my vital signs can you show me what my vital signs were
[doctor] yeah that's uh uh that's a really good question so our big and favorite one is gon na be your blood pressure right so you're right like we are seeing some some definite improvement today it was one twenty over seventy and honestly that's a great place to be so that tells me that your medication is working and that maybe we can start to evaluate a bit more your respiratory rate is completely normal so i see it here as eighteen that's wonderful you are not running a fever so ninety seven . nine and you're honestly that's within like a good enough range for me you're satting pretty well your oxygen saturation is a hundred percent again so that means that you're not experiencing any kind of difficulty getting in that oxygen to the rest of your body i do wan na say that you know pain is one of the vitals that we worry about and you're saying that at it's worst your the pain in your elbow is a seven out of ten so that's something that i'm gon na evaluate and then your pulse rate seems to be appropriate as well so those are all great do you have any questions about that so far
[patient] no that sounds good yeah i was just curious
[doctor] yeah
[patient] checked it in a while so
[doctor] mm-hmm i do wan na say that like looking at your the weight we do see like maybe a five pound increase from the last time that you were here but that's completely normal right to be able like to fluctuate you know give or take five pounds so i'm not i'm not i'm not like seriously worried about it but if we do come back and notice an additional five pounds then we might have to start talking about like actually you know what let's do that right now what kind of exercise regimen are you on
[patient] well i do go for some walks in the evening i try to get one in on the morning too
[doctor] mm-hmm
[patient] so not a whole lot other than that because i'm busy with my pottery or baking so but i do try to get out and walk daily
[doctor] okay that's awesome so like how about about how long are your walks
[patient] well i just walk around the neighborhood there is you know the sidewalks and there is kind of a little bit more of a nature type area that goes across the bridge and so it's probably you know maybe one to two miles a day
[doctor] wow that's intense i was not expecting that number that's awesome okay alright so maybe this five pounds is muscle we're gon na go for it okay but thank you but that's some really important information but i'm gon na start your physical exam now okay
[patient] okay
[doctor] alright so i know that you said that you are experiencing elbow pain could you tell me is it your left or your right elbow
[patient] it's my right
[doctor] okay alright right elbow when i touch it does it hurt on the inside
[patient] yes it does
[doctor] okay so moderate tenderness at the medial epicondyle when you turn like when you turn your wrist is if you're trying to open a door knob do you experience pain
[patient] no not really
[doctor] alright so turning out no pain but when you turn your wrist inwards do you have any pain
[patient] yeah
[doctor] okay so pain with resisted pronation of right forearm when you rest your arm on a table with the palm side up alright i want you to raise your hand by bending the wrist do you experiencing any pain
[patient] yeah that hurts
[doctor] alright alright so when you are when i'm pressing here and like flexing your wrist are you experiencing any pain
[patient] yes
[doctor] alright pain with flexion and when bending the wrist alright when i listen to you you know i'm just gon na check your heart and lungs everything sounds sounds good no murmur no rub no gallop your lungs are clear bilaterally to bilaterally to auscultation i'm not noticing any rash for your at your elbow i do n't notice any bruising any swelling we do wan na note that tenderness but otherwise there is no discoloration no lesions so that's good your pulses and are equal bilaterally and i think i think we have an idea of what we are dealing with here okay so i'm gon na go ahead and give you my impression and plan for your your first problem like your primary problem that you are here for is right elbow pain it's consistent with medial epicondylitis and that it just means it's pain caused from overuse and damage to the tendons in your arm what we are gon na do is rest it i'm gon na order a sling for your right arm and you can wear this while you're awake well i want you to apply ice to your elbow for twenty minutes three times a day i'm going to i'm gon na ask you to take six hundred milligrams of ibuprofen that's three pills every six hours with food and you can take that for one week i know it's really important that you said that you have something that a gift that you wan na make for your son but we're gon na hold off on pottery for the next couple of weeks just to give your arm a chance to heal you know like it's awesome that you wan na be able to do these things for your family but sometimes you know your body is not where your where your where your heart is like where your heart and your head are right and then so
[patient] i'll i'll just let him know that that i maybe i'll take a picture of what i have so far
[doctor] absolutely that's awesome and so it'll be like a a movie like coming soon to a shelf near you that's great for your second problem right we have this longstanding diabetes i want to increase your metformin to a thousand milligrams twice a day i know that you're saying you're having a hard time keeping up with that so i want you to do a good job of like checking and recording your blood sugars every day i do need you to follow up with me in a couple weeks i also wan na order something called an a1c since you are having a hard time with like the blood like the blood sugars everyday an a1c will give me a more accurate picture of like a longer period of time and then we might need to evaluate like what are what other options that we have if your sugars if we ca n't get them a bit more under control i do want you to follow up with me in a couple of weeks about the about your diabetes and for your third problem of hypertension we're just gon na continue you on your lisinopril at ten milligrams that's it seems to be doing it's job i'm really i'm really glad about that and it's probably due to the walking that you're doing i forgot to mention for your diabetes we are gon na i'm gon na recommend a a referral to diabetic counseling that way you can get like a bit more information on like the steps that you can take to help you with that
[patient] i was gon na ask you how about my x-ray the x-ray of my elbow how did that look
[doctor] your x-ray honestly looks great in that i do n't see any kind of fracture or bony abnormality so that's what makes me think that this is like a tendon related thing right so in reviewing your x-ray like it it does support the the the assessment and plan that i have given you i
[patient] okay
[doctor] do you
[patient] just true
[doctor] yeah absolutely i do think for your your primary problem the elbow that we might wan na get put you in some physical rehab if the problem is taking a little longer to heal but we'll discuss that at your next visit here okay
[patient] okay
[doctor] alright no problem any other questions
[patient] nope
[doctor] alright thank you for keeping me accountable

CHIEF COMPLAINT

Right elbow pain.

HISTORY OF PRESENT ILLNESS

Teresa Sullivan is a pleasant 33-year-old female who presents to the clinic today for the evaluation of right elbow pain. Her pain began 4 days ago, without any improvement. She denies any specific injury; however, she has recently increased her usage of a pottery wheel in creating a bowl for her son. She is currently unable to work with the pottery wheel secondary to pain. Her pain is in the medial aspect of her elbow. She notes it radiates medially down her arm as well. The patient rates her pain level as 7 out of 10 at its worst. She reports the pain wakes her at night if she rolls over. She denies ibuprofen or ice provide pain relief. The patient denies any previous elbow injuries.

The patient has a history of hypertension. She states she has been checking her blood pressures regularly. She adds that her blood pressures have been in the 110s to 130s range. She affirms she is taking lisinopril 10 mg daily and denies missing doses.

Regarding her diabetes type 2, she reports she sometimes forgets to take metformin 500 mg twice daily. At times, her blood sugar levels range from 150 to 170 mg/dL. She states that she has a sweet tooth and indulges in home baked goods. For exercise, she walks in the evening and in the morning. She walks 1 to 2 miles per day around her neighborhood.

The patient enjoys working with ceramics as well as baking cakes and cinnamon rolls for family gatherings.

MEDICAL HISTORY

Patient reports history of hypertension and diabetes type 2.

MEDICATIONS

Patient reports taking lisinopril 10 mg and metformin 500 mg twice daily.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right elbow pain.

VITALS

Blood Pressure: 120/70 mmHg.
Pulse Rate: Appropriate.
Respiratory Rate: 18 breaths per minute.
Oxygen Saturation: 100% on room air.
Body Temperature: 97.9 degrees F.
Pain Level: 7/10 at its worst.
Weight: 5 lb increase since last visit.

PHYSICAL EXAM

CV: No murmurs, gallops or rubs. Pulses are equal bilaterally.
RESPIRATORY: Normal respiratory effort, no respiratory distress. Lungs are clear bilaterally to auscultation.
SKIN: No rash or lesions.
MSK: Examination of the right elbow: Moderate tenderness at the medial epicondyle. Pain with resisted pronation of the right forearm. Pain with flexion and bending the right wrist. No bruising or swelling. No discoloration or lesions.

RESULTS

An x-ray of the right elbow was reviewed today. It demonstrated no evidence of any fractures. No other abnormalities are noted.

ASSESSMENT

1. Right elbow pain, consistent with medial epicondylitis.
2. Diabetes type 2.
3. Hypertension.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with her regarding her current symptoms. I have explained to her that her elbow pain is consistent with medial epicondylitis and was most likely caused by overuse and damage to the tendons in her arm. I have recommended that we treat the patient conservatively. The patient will wear a sling on her right arm while she is awake to provide increased support. I advised her to ice her right elbow for 20 minutes 3 times per day. She will take ibuprofen 600 mg every 6 hours with food for 1 week. I have also advised her to hold off on creating pottery for the next 2 weeks to allow her arm to heal. If the patient continues to experience persistent elbow pain, we may consider formal physical therapy at her next visit.

I have encouraged the patient to check and record her blood sugars every day. I will increase her metformin to 1000 mg twice a day. The patient and I discussed the importance of her taking her medication on a regular basis twice a day. I have also recommended that she be referred to diabetic counseling for more information on the steps she can take to manage her diabetes. I will also order a hemoglobin A1c test for a more accurate assessment of her long-term blood sugar levels.

The patient’s hypertension is currently controlled with medication and exercise. I have instructed her to continue taking lisinopril 10 mg. I also encouraged her to continue with her walking routine.

All questions were answered.

INSTRUCTIONS

The patient will follow up with me in 2 weeks to review the results of the hemoglobin A1c test and discuss her progress.


[doctor] good morning noah tell me a little bit about why you are here today
[patient] hi document i'm i'm just had you know the back pain you know and i've i've had it for you know about a week and
[doctor] oh
[patient] you know i mean i tried some you know i mean medications but you know some over the counter stuff but it does n't go away
[doctor] okay can you tell me a little bit more about it how did it start or how did it do you remember injuring yourself
[patient] no not really i mean i was just like you know i guess i one day i mean i just twisted you know on my left and maybe i mean i might have picked something up
[doctor] okay
[patient] so i mean at that time i mean there was this pain but i you know it went away you know and i thought that was you know that was you know the end of it but you know i mean after you know a few hours you know it's it kinda it came back
[doctor] okay
[patient] it's been there since then you know
[doctor] okay and is it anywhere in specific is it in the middle of the back across the whole low back or on one side or the other
[patient] i think it's more towards you know right in the middle maybe on the lower side and nothing on the you know i mean it sometimes it goes back you know maybe having troubles with the left eye i suppose but i mean it's aggravated you know when i you know when i do some you know maybe i'm a sudden movement to the left
[doctor] okay and that's when you get the pain more maybe located in the center but it goes across to the little back and i on the left side and i also heard you say you know if you twist suddenly that makes it worse is that correct
[patient] it makes it worse it makes it worse i mean yeah
[doctor] now you know i was looking at your records and i know you have that history of diabetes and i have n't seen you a while for a follow-up for that how you've been feeling
[patient] i mean been okay i mean i take my meds
[doctor] okay
[patient] and i try to still have sugar but you know i mean i you know you know i mean whenever i get the chance i mean i you know i exercise but you know i mean that's about it
[doctor] okay so you're on
[patient] mm-hmm
[doctor] yeah i think i think you're on that metformin twice a day
[patient] yeah
[doctor] yeah okay
[patient] yes
[doctor] do you test your blood sugar at home in the mornings
[patient] yeah i mean i try to
[doctor] okay
[patient] most of the morning but sometimes i mean i go skiing yeah
[doctor] and how have those numbers been
[patient] they bumped towards i mean bit towards the higher side i mean i must have been
[doctor] okay
[patient] you know but
[doctor] well if
[patient] yeah
[doctor] yeah if i remember right your family do n't they own that that bakery down on the corner of main street and did n't they own that
[patient] yeah thank you
[doctor] and how do you do you stay away from those i i got ta be honest i love i love the cakes and donuts they make those are delicious
[patient] yeah i try to
[doctor] okay
[patient] but i mean you know they they you know i have to visit them and you know i end up you know i mean getting some stuff but it's not that much
[doctor] okay
[patient] but it's been i try to contain it you know
[doctor] well let me so we're gon na have to watch that and i'll come back and we'll talk a little bit about the diabetes but let's go ahead and do that i do n't wan na do a a a quick physical exam on you i'm gon na look in your eyes here and so let me quickly look in your ears
[patient] i see
[doctor] okay that looks good and any let me let me listen to your lungs okay your lungs are clear and your heart it's a regular rate and rhythm that's all good as we go through that now i want you to sit up here i'm gon na press down your back starting at the top and any pain up top no
[patient] no
[doctor] okay and then once i get down here and around that low back i wan na press in the center first does that cause you a lot of pain
[patient] yeah
[doctor] yeah okay
[patient] yeah that that's the spot
[doctor] okay and if i come over here to the right no
[patient] not that much you know
[doctor] okay so and then on the left hand side if i push down here kind of into your butt
[patient] yeah
[doctor] yeah okay
[patient] yeah
[doctor] lay back on the stretcher for me for a second i'm gon na go ahead and and lift your legs for me or i'm gon na go ahead and lift your legs for you just relax i'm gon na start here on the right side when i lift that right leg up does that cause you significant pain or any pain at all
[patient] a little a little bit
[doctor] okay let me come around let me lift up the left side if i lift that up does that cause
[patient] yeah yeah yeah that's that's
[doctor] yeah
[patient] still get tender yeah
[doctor] i can see that gritts on your face so okay that's good and you know as i look at your lower extremities there is no pain or numbness or tingling in your feet or anything like that
[patient] hmmm no
[doctor] okay okay so lem me talk a little bit about my impression and plan so for that low back pain i believe you have a musculoskeletal low back strain i'm going to order a low back x-ray so we'll order that and get that done as an outpatient i do n't expect to see anything significant but it's gon na tell me how those joint spaces look and if you know if we're dealing with any disk issue but that will be the start of it and i'm also gon na order some physical therapy two for two reasons to help with a little bit with the pain but also strengthen some of the muscles there in the back so those are the two things that we are gon na do now i want you to take take four hundred milligrams of ibuprofen you can take that occasionally with some tylenol when the pain gets more severe up to about three times a day i'm gon na also give you a prescription for some flexeril that's a muscle relaxant and i want you to take one of those once a day every evening but be careful if you're doing any strenuous or hazardous activities such as driving after you take those now for your diabetes my impression is that your diabetes is is under control i noticed that we do n't have n't had a a1c for almost five months so i'm also gon na order an a1c so we can find out where we are with that continue with your diet and exercise we know that's really important and then continue with your metformin i'm not gon na make any changes today but we'll go ahead and look at that once i get that results of that a1c do you have any questions for me
[patient] yeah can i still go to the bakery
[doctor] i would yes it's nice for you to go to the bakery but you ca n't have any donuts i'm no i you just really need to watch that intake of of anything that you might get at the at the bakery so just just be careful with those carbohydrates those sweets that you're taking as we go through your day it's occasional occasional one perfectly fine but on a routine basis we need to watch that
[patient] right and how soon should i you know check my blood sugars i mean what's a good you know
[doctor] yeah i that's a great question i'm really glad you asked that i would prefer that you're taking your blood pressure every morning the first thing you get up when you get up in the morning that's gon na give me a good idea and so if you can do that the first thing in the morning and keep a record of it you know i know your glucometer keeps a record of it but if you can write them down and once we get that a1c that's gon na give me a little more guidance on how to deal with your blood your diabetes
[patient] right do you think would i need to see you know a pain doctor or you know
[doctor] not yet let's let's get the that's a great question i may end up referring you to a a pain doctor for that low back pain but i really would like to start with some of the diagnostics first let's get an x-ray and if there is you know any question of that x-ray and the pain continues i'm gon na go ahead and maybe order a cat scan and then at that point in time we can refer you to a pain doctor if we're still having significant pain
[patient] sounds good
[doctor] okay thank you i'm gon na send my nursing to see you and we'll get you out the door
[patient] thank you
[doctor] take care
[patient] that one is a follow-up mm-hmm

CHIEF COMPLAINT

Back pain.

MEDICAL HISTORY

Patient reports history of diabetes.

SOCIAL HISTORY

The patient's family owns and runs a bakery.

MEDICATIONS

Patient reports taking metformin twice daily.

REVIEW OF SYSTEMS

Musculoskeletal: Reports back pain.
Neurological: Denies numbness or tingling in feet.

PHYSICAL EXAM

Eyes
- Examination: No redness, discharge, or icterus.

Ears, Nose, Mouth, and Throat
- Examination of Ears: Auditory canal and tympanic membranes are clear.

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm.
Musculoskeletal
- Examination: No pain to palpation of the upper back. Pain to palpation of the midline of the lower back, especially on the left. No pain to palpation on the right lower back. Mildly positive straight leg rise on the right Positive straight leg rise on the left.

ASSESSMENT AND PLAN

1. Low back pain.
- Medical Reasoning: I believe he has a musculoskeletal low back strain. I do not expect to see anything significant on x-ray, but we will obtain one for further evaluation of any possible disc issues.
- Patient Education and Counseling: We discussed his diagnosis at length today. I explained that physical therapy can help with the pain, but also strengthen some of the muscles in the back. I explained that he needs to be careful while taking medications, such as an overuse of muscle relaxers if he is doing any strenuous or hazardous activities such as driving.
- Medical Treatment: Low back x-ray ordered. Referral to physical therapy provided. He will take 400 mg of ibuprofen up to 3 times per day. Tylenol can be used for severe pain. Prescription for Flexeril also provided.

2. Diabetes.
- Medical Reasoning: His diabetes is currently under control.
- Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. I encouraged him to try an avoid foods high in sugar. He asked many questions and I feel he is confident in the plan at this point.
- Medical Treatment: Hemoglobin A1c ordered as he has not had an updated one in almost 5 months. He will continue with his diet and exercise. Continue current dose of metformin for the time being. The patient will be checking his blood sugar in the morning and will log this information for me.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.


[patient] i hope i did n't hurt it again
[doctor] hi gregory how are you i the medical assistant told me that you injured your knee
[patient] yeah yeah i heard it stepping off a curb
[doctor] how long ago did that happen
[patient] about two and a half weeks ago
[doctor] two and a half weeks ago and what what knee is bothering you
[patient] the right knee the outside of my right knee
[doctor] the outside of your right knee
[patient] yeah
[doctor] okay and did you actually fall down when this happened or
[patient] no i just sorta turned over my ankle
[doctor] okay
[patient] to the outside and i thought my ankle was the thing that was gon na hurt most but after the ankle soreness went away the only my knee hurt and it sort of clicks when i walk
[doctor] and no okay so now it clicks when you walk okay does it hurt when you walk
[patient] no unless i stand on one foot for an extended period of time like leaning my foot up against the wall
[doctor] okay
[patient] then i feel like it's locked and then i sort of have to ease into walking again
[doctor] okay and what have you taken for the pain
[patient] really nothing
[doctor] okay
[patient] ibuprofen but i'm not a big pill taker so i sort of sucked it up and
[doctor] does the ibuprofen work
[patient] at night you know during the day i'm more active so it it really does n't impact it because i just work through it but at night it does help me to settle down and sleep better
[doctor] does your knee hurt when you're just resting and sitting there
[patient] no when it's up it's fine when it's down on the floor with my foot flat it's fine it does hurt when i rest it on my heel
[doctor] okay and are you able to do things like bending or things like that
[patient] a full squat that's when i feel the most clicking like if i go all the way down to a full squat like a catcher that's when i feel the most clicking but otherwise no there is no pain it's just the clicking and i'm fearful that that's an injury of some type
[doctor] okay alright now you said squats are you are you active are you doing like burpees going to
[patient] no i ride the bike
[doctor] okay
[patient] i ride the bike i ride the bike which i'm not doing now peloton inside for the winter i do have a winter bike though
[doctor] okay alright well i have a peloton who is your favorite instructor
[patient] i i actually do n't have a favorite instructor i have more favorite rides
[doctor] okay what kind of rides do you like
[patient] i like rock music and regain music rides so whoever is doing those in a began or a medium content i'm cool with
[doctor] i ca n't picture you as a regade person so that's interesting to know okay alright and any numbing or tingling in your foot at all
[patient] yes but not from the knee injury i broke my foot my second toe on my right foot and i have numbness depending upon the shoe i wear
[doctor] okay when did you break your toe
[patient] i've broken it three times over the last ten years so it's just something that's a an annoyance but it was n't caused by this injury
[doctor] okay so you do have some numbing and tingling but it's not new
[patient] right correct
[doctor] alright alright well let's just go ahead and i'm gon na go ahead and do a quick physical exam i'm gon na be calling out my exam findings i'll let you know what that means so on your musculoskeletal exam on your right knee i do appreciate some slight edema you do have a slight effusion does it hurt when i press on the outside of your knee
[patient] no not physically
[doctor] okay there is no pain to palpation of the right lateral knee i'm gon na be bending your knee in all sorts of positions does that hurt
[patient] only when you pull it to the outside
[doctor] okay
[patient] from my my foot when you pull it to the outside that's the only time it hurts
[doctor] okay the patient has a positive varus test there is full range of motion there is a negative lachman sign the patient does on cardiovascular exam the patient does have a palpable dorsalis pedis and posterior tibialis pulse okay well let's just i wan na talk a little bit about i had the nurse do an x-ray on you and i looked at the results of your knee x-ray and it does n't show any acute fracture or bony abnormality which is not surprising based on your injury so let's just talk a little bit about you know my assessment and my plan for you so i think you do have a a lateral a lateral collateral ligament strain based on your exam findings and this this type of injury essentially can be healed by itself you know i do n't think we're gon na need to refer you to surgery or anything like that i want you to go ahead and i'm gon na prescribe meloxicam fifteen milligrams once a day i do wan na go ahead and refer you to physical therapy because if we strengthen up those muscles and areas around that injury then that will make your knee stronger it help prevent future injuries are you able to ice it at all during the day now you said you working you work in sales so you said you're home
[patient] yeah i actually i'm at home so i can ice it and i have been icing it
[doctor] okay
[patient] i mean twenty on twenty off at least four times a day
[doctor] okay and so does that help at all
[patient] it's it it makes it feel better in the morning when i first go to my desk and at the end of the day before bed you know i take ibuprofen so i do n't have swelling overnight but honestly i have a pretty decent threshold for pain so it's not good it's not changing it by much
[doctor] okay do you feel like your symptoms are getting worse or better i think i think pretty much for the last two weeks they've remained about the same the the only time i feel like they get worse is when i exert myself doing up and down like gardening in the yard or moving pots
[patient] and stuff outside that's the only time i felt like it got any worse but nothing to the point where it stayed worse
[doctor] okay alright well let's go ahead and refer you to physical therapy if you're still having pain then we might have to consider an mri
[patient] okay
[doctor] any questions about that
[patient] no
[doctor] okay alright well it was very nice seeing you today call me if you need anything
[patient] i will
[doctor] okay bye
[patient] bye

HISTORY OF PRESENT ILLNESS

Gregory Price is a pleasant 68-year-old male who presents to the clinic today for the evaluation of a right knee injury. The onset of his pain began 2.5 weeks ago, when he stepped off of a curb and turned over his ankle. He locates his pain to the lateral aspect of his right knee. The patient also reports clicking with ambulation. He denies any pain with ambulation unless he stands on one foot for an extended period of time. The patient also reports locking of his knee with prolonged standing. He notices pain when he is resting his foot on his heel. He denies any pain at rest and elevated, or when his foot is flat on the ground. The patient states that he is more active during the day, which does not impact his knee pain. He adds that he is able to perform a full squat without pain. The patient reports numbness and tingling in his right foot, however this is not new. The patient has been taking ibuprofen, which provides him with relief at night. He has also been icing his knee 4 times per day, which provides him with relief in the morning and at the end of the day.

MEDICAL HISTORY

He states that he has fractured his 2nd toe 3 times over the last 10 years.

SOCIAL HISTORY

The patient works in sales. He rides a bike for exercise.

REVIEW OF SYSTEMS

Neurological: Positive for numbness and tingling in his toes on his right foot from prior injury.

PHYSICAL EXAM

CV: >Palpable dorsalis pedis and posterior tibialis pulse.
MSK: Examination of the right knee: Slight edema. Slight effusion. No pain with palpation of the right lateral knee. Positive varus test. Full ROM. Negative Lachman's.

RESULTS

4 views of the right knee were taken. These reveal no evidence of any fractures, dislocations, or bony abnormality. No other abnormalities are noted.

ASSESSMENT

Right knee lateral collateral ligament strain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any acute fractures or bony abnormality. I have recommended that we treat the patient conservatively with formal physical therapy to strengthen his right knee. I have also prescribed the patient meloxicam 15 mg to treat his pain. If his pain does not improve with physical therapy, I will recommend obtaining an MRI.