[doctor] hi richard how are you the medical assistant told me that you have a tick bite is that what happened
[patient] i really do n't know where i got it but i i had i do get out in the woods and i do spend a lot of time out in the yard but yeah i've got a tick bite around my knee and and it's been it's been over a week and and just it just burns and just quite annoying
[doctor] okay and have you had any fever or chills
[patient] i have not at this point it just feels warm on that spot
[doctor] okay alright and have you noticed any other joint pain like in your elbows or shoulders or anything like that that since this started
[patient] nothing other than my typical arthritic pain
[doctor] okay alright now you say that you like to go outside and and you're working in the yard now i i heard that you were a a hunter when was the last time you went hunting has hunting season started yet i do n't even know
[patient] well i i did go hunting not long ago couple of weeks ago
[doctor] okay did you did you
[patient] windle season is open well it it's actually on a on a a got the right word for it but it it's where they train dogs and things like that
[doctor] okay
[patient] type thing
[doctor] okay did you i did did did were you able to shoot anything did you bring anything home
[patient] well actually i yeah i shut several i had some grandchildren with me so i let them have what they wanted
[doctor] nice nice you know i i did hear i do n't know much about hunting but i did hear a hunting software joke the other day do you want to hear it
[patient] sure
[doctor] so what software do hunters use for designing and hunting their pray
[patient] man i have no idea
[doctor] the adobee illustrator get it
[patient] do n't be
[doctor] anyway i die grass let's just get back to our visit here so about your line or about your tick bite so do you notice that it's hard for you to move your knee at all
[patient] not at this time no
[doctor] no and do you have any problems walking
[patient] no
[doctor] no okay and have you ever had a tick bite before
[patient] i have when i was younger i used to get a lot of them because i spent a lot of time out of the woods never get into anesthesia takes you can get several bites out of that but this was just one
[doctor] okay alright and have you ever been diagnosed with what we call lyme disease before
[patient] i have not
[doctor] you have not
[patient] i would n't know so i would n't know what symptoms are
[doctor] okay
[patient] what you just asked me i guess maybe
[doctor] yeah so some of those symptoms like any flu like symptoms have you had like any body aches or chills or anything like that
[patient] no just really just kind of a a headache just generally do n't feel well
[doctor] generally do n't feel well okay and has that been since the tick bite
[patient] it has
[doctor] it has okay alright and any other symptoms like a cough or shortness of breath or dizziness or anything like that
[patient] no
[doctor] okay now since you are here let me just ask you a little bit about your high blood pressure did you buy the blood pressure cuff i asked you to have you been checking your blood pressure at home
[patient] periodically yes
[doctor] okay and do you think that they are running okay
[patient] yeah blood pressure seems to be doing okay the lisinopril works well
[doctor] good i was just gon na ask you if you were taking your lisinopril so that's good okay and any side effects from the lisinopril since we started it i think we started it about a year ago two years ago
[patient] no no no side effects that i'm aware of
[doctor] no side effects okay and then in terms of your diabetes are you watching your sugar intake
[patient] yeah i usually watch it the form of high what i'm eating but
[doctor] i am a big pie fan as well i know what's your favorite type of pie
[patient] well you know it's favorite boy i just like pie you know apples cherry chocolate you know bicon
[doctor] yeah
[patient] i try to try to avoid the bicon because i think it's just all sugar but i do like it
[doctor] okay
[patient] less
[doctor] i like it too alright are you taking the metformin twice a day
[patient] not everyday but most of the time
[doctor] okay alright and are you checking your blood sugars pretty regularly
[patient] i try to
[doctor] okay and do you do you know on average how they're running are they running below like one fifty or
[patient] yeah it's definitely running below that
[doctor] okay your blood sugars are running below
[patient] it's it's probably with with with the metformin it seems to be you know one twenty
[doctor] good
[patient] pretty regular
[doctor] good your blood sugars are running in the one twenties that's really good okay alright well i wan na just go ahead and do a quick physical exam okay so i'm looking here at your vital signs and your vital signs look really good i do think you're doing a good job with taking your lisinopril your blood pressure's about one twenty two over seventy right now which is right where we want it your heart rate is nice and slow at sixty seven again which is right where we want it and i do n't appreciate any fever today you you have a normal temperature at ninety eight . four which is really good so i'm just gon na be going ahead and calling out some physical exam findings and i'm gon na let you know what that means when i'm done okay so on your heart exam your heart is in a nice regular rate and rhythm i do n't appreciate any murmur rub or gallop on your lung exam your lungs are nice and clear to auscultation bilaterally on your right knee exam i do appreciate some erythema and edema as well as an area of fluctuance over your right patella now does it hurt when i press
[patient] it's a little bit sore
[doctor] okay there is pain to palpation of the right anterior knee and i'm just gon na bend your knee up and down does that hurt at all
[patient] no no it's just more of the typical grinding that i would feel
[doctor] okay there is full range of motion of the right knee and on skin examination there is evidence of a bull's-eye rash over the right knee okay so what does that mean richard so that means that you know you do have some area of some inflammation over the over the right knee where you where you have that tick bite and you do have what we call that bull's eye rash which is what we get concerned about with with lyme disease so let's just talk a little bit about you know my assessment and my plan for you okay so for this first problem of your of your tick bite my concern is that you might have lyme disease based on the presentation of your right knee so i'm gon na go ahead and start you on doxycycline one hundred milligrams twice a day
[patient] we're gon na continue that for about three weeks i'm also gon na go ahead and send a lyme titer as well as a western blot to see if you do in fact have lyme lyme disease and we'll have to go ahead and just see how you do with this we you know i'd like to avoid intravenous antibiotics which i think we can avoid but i wanted to see how you do so
[doctor] do you have any questions about that
[patient] yeah i did n't know what those last two things or just
[doctor] yeah so so we are gon na start you on some antibiotics to help help you with this
[patient] you know possible lyme disease and i'm gon na just order some blood tests just to see exactly what's going on and then you know sometimes people need intravenous antibiotics because lyme disease can cause problems on other organs like your heart that type of thing
[doctor] if not treated appropriately and sometimes we need to give antibiotics through the iv which i'd like to avoid i think that we got this early enough that we can just treat you with some oral antibiotics okay for your second problem of your hypertension you know i think you're doing a really good job let's go ahead and continue you on the lisinopril twenty milligrams once a day and i wan na just go ahead and order a lipid panel just to make sure that everything is okay with your cholesterol how does that sound
[patient] that's fine
[doctor] great and then for your third problem of your diabetes i wan na just go ahead and order a hemoglobin a1c and continue you on the metformin one thousand milligrams twice a day it sounds like you're doing a good job since your blood sugars are running in the one twenties i do n't think we need to make any adjustments but we'll see what the hemoglobin a1c shows that gives us a an idea of what your blood sugars are doing on a long-term basis how does that sound
[patient] okay at what point time do you start kinda checking kidney function i've been told that metformin can possibly cause some kidney issues
[doctor] so it can you know your kidney function we've you know i think you've been really lucky it's been normal i checked it about two months ago and it looks pretty good it looks pretty normal but since we're doing blood work on you i can go ahead and order a a basic metabolic panel just to make sure that your kidney function is stable
[patient] okay that'd be good
[doctor] okay anything else
[patient] not that i can think of at this time as soon as i leave
[doctor] well you know where to find me okay
[patient] alright
[doctor] take care bye

CHIEF COMPLAINT

Tick bite.

MEDICAL HISTORY

Patient reports a history of arthritis, hypertension, and diabetes type 2.

SOCIAL HISTORY

Patient reports he enjoys spending time outside in the woods and working in the yard. He went hunting with his grandchildren a couple of weeks ago.

MEDICATIONS

Patient reports taking lisinopril 20 mg once a day and metformin 1000 mg twice daily most of the time.

REVIEW OF SYSTEMS

Constitutional: Reports general ill feelings. Denies any fever, chills, flu like symptoms, body aches, or trouble waking.
Respiratory: Denies cough or shortness of breath.
Musculoskeletal: Denies joint pain or problems with ambulation.
Skin: Reports warmth on the right knee.
Neurological: Reports headache. Denies dizziness.

VITALS

Blood Pressure: 122/70 mmHg.
Heart Rate: 67 beats per minute.
Body Temperature: 98.4 degrees F.

PHYSICAL EXAM

Neck
- General Examination: Neck is supple without thyromegaly or lymphadenopathy.

Respiratory
- Auscultation of Lungs: Clear bilaterally.

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

Musculoskeletal
- Examination of the right knee: Erythema and edema as well as an area of fluctuance noted over the right patella. There is pain to palpation of the right anterior knee. Full range of motion.

Integumentary
- Examination: There is evidence of a bull’s eye rash over the right knee.

RESULTS

Patient's previous kidney function is within normal limits.

ASSESSMENT AND PLAN

1. Tick bite.
- Medical Reasoning: My concern is that he might have Lyme disease based on the presentation of his right knee.
- Patient Education and Counseling: The patient and I discussed blood testing to determine if he does in fact have Lyme disease. I explained that Lyme disease can cause problems with other organs if not treated appropriately. We discussed that sometimes antibiotics need to be administered intravenously if oral antibiotics are not given early enough. We will see how he does with a course of oral antibiotics as I would like to avoid intravenous antibiotics.
- Medical Treatment: Prescription for doxycycline 100 mg twice a day for 3 weeks provided. Lyme titer and Western blot will be obtained to determine if he has Lyme disease.

2. Hypertension.
- Medical Reasoning: This is well-controlled at this time.
- Patient Education and Counseling: The patient and I discussed that he is doing really well monitoring his blood pressure at home.
- Medical Treatment: Continue lisinopril 20 mg once a day. Lipid panel ordered to assess his cholesterol levels.

3. Diabetes type 2.
- Medical Reasoning: He is doing a good job managing his diabetes since his blood sugars are running in the 120s. I do not think we need to make any adjustments, but we will see what the hemoglobin A1c shows as that gives us an idea of what his blood sugars are doing on a long-term basis.
- Patient Education and Counseling: We discussed that metformin can affect kidney function; however, his kidney function was last checked 2 months ago, and it has remained within normal limits.
- Medical Treatment: Continue metformin 1000 mg twice a day. Hemoglobin A1c ordered. Basic metabolic panel ordered to assess kidney function.

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


[doctor] karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you
[patient] i'm okay i guess
[doctor] hey dad how are you doing
[patient] hey doc i am okay yeah karen has been having this eye twitch i noticed a couple of weeks ago when i talked to her pediatrician and they told me to come see you
[doctor] okay alright so karen have you felt the twitch
[patient] yeah well i mean i feel my face sometimes
[doctor] yeah and do you have any pain when it happens
[patient] no it it does n't really hurt but i noticed that dad looks real nervous when it happens
[doctor] yeah i i i can understand that's because he loves you do you feel the urge to move your face
[patient] sometimes and then it moves and then i feel better
[doctor] okay okay and so so dad how often are you seeing the twitch on karen
[patient] i do n't know i mean it varies sometimes i see it several times an hour and there is other days we do n't see it at all until sometimes late afternoon but we definitely notice it you know everyday for the last several weeks
[doctor] okay so karen how is how is how is soccer
[patient] i like soccer
[doctor] yeah
[patient] yeah dad dad takes me to play every saturday
[doctor] okay
[patient] it's it's pretty fun but there's this girl named isabella she she plays rough
[doctor] does she
[patient] she yeah she tries to kick me and she pulls my hair and
[doctor] oh
[patient] sometimes she's not very nice
[doctor] that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson
[patient] yeah and and then sometimes after soccer we we go and i get mcdugge's and it and it's it makes for a nice day with dad
[doctor] is that your favorite at mcdonald's in the the mcnuggates
[patient] not not really but they are cheap so
[doctor] okay alright well you you made dad happy at least right
[patient] yeah that's what he says because i'm expensive because i want dresses and dogs and stuff all the time
[doctor] yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens
[patient] no i mean when it happens she just continues playing or doing whatever she was doing when it happens
[doctor] okay alright has she has she otherwise been feeling okay since this started has she been acting normally
[patient] i i'd say she seems fine i mean she has been eating well and playing with her friends and she goes about her normal activities really
[doctor] okay good
[patient] never even though anything was going on
[doctor] okay alright good so has has karen had any seizures in the past
[patient] no
[doctor] no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching
[patient] well no uh it's just her face
[doctor] okay
[patient] i mean the whole side of her face moves when it happens it seems like it several seconds and then it finally stops and she just seems to be blinking frequently and and and you know wait a minute i i did make a video so you can see just in case it does n't do it during the visit
[doctor] okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome
[patient] well no history of seizures but i i i never heard of that tourette thing
[doctor] yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger
[patient] really i had nobody in our family got anything like that
[doctor] okay now tell me have you noticed any other symptoms how about like fever or chills
[patient] no
[doctor] okay coughing headache
[patient] ma'am
[doctor] okay how about any problems with karen's sleep
[patient] nope
[doctor] okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay
[patient] okay
[doctor] alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there
[patient] mm-hmm
[doctor] does that feel the same
[patient] yeah
[doctor] okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator drift sensation is intact reflexes are two plus and symmetric at the biceps triceps knees and ankles so this means everything looks good karen
[patient] that's great
[doctor] good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school years and tics can also include things like shoulder shrugging facial grimacing sniffling excessive throat clearing and uncontrolled vocalization i can say that essentially they're brief sudden and involuntary motor movements now we do n't have a full understanding of the cause of the tics but they typically occur around five to ten years of age but most ticks go away on their own and they disappear within a year so these are what we call transient tics and the best thing to do is ignore the tics so it does n't seem to be bothering karen and she seems to be doing well in school and activities so it may wax and wane over time but you might notice it more towards the end of the day when the child is tired so you may also you know see it if they're stressed so that's why it's important to just ignore it now when you draw attention to the tick it does make the child conscious so that can make the tic worse so we want to be careful again just to to kind of not to draw too much attention on it and do you have any questions for me
[patient] so you mean you're telling me you do n't think he had a seizure or a bit or nothing
[doctor] yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards
[patient] so you're not recommending any kind of treatment there is no pill or cream or nothing
[doctor] not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay
[patient] alright alright sounds good
[doctor] alright thank you you guys have a good day
[patient] doctor
[doctor] bye karen

CHIEF COMPLAINT

Right eye twitch.

SOCIAL HISTORY

The patient plays soccer every Saturday, however she has noted that there is a girl that tries to kick her and pulls her hair.

FAMILY HISTORY

Patient's father reports that they do not have a family history of seizures or Tourette's syndrome.

REVIEW OF SYSTEMS

Constitutional: Denies fever, chills, or changes in appetite.
Eyes: Reports right eye twitch. Denies right eye pain.
Respiratory: Denies cough.
Neurological: Denies headaches or sleep disturbances.

PHYSICAL EXAM

Neurological
- Orientation: Alert and oriented x3. Speech is clear and fluent. Gait is steady. Heel toe walking is normal. Cranial nerves grossly intact without focal neurologic findings. No pronator drift. Sensation is intact. Reflexes are 2+ and symmetric at the biceps, triceps, knees, and ankles.

ASSESSMENT AND PLAN

1. Transient tics.
- Medical Reasoning: The patient's father provided a video today as she did not have a twitch in office. It appears the patient is experiencing a tic.
- Patient Education and Counseling: Nature of the diagnosis was discussed today with the patient and her father. I advised eye tics are very common in children and as many as 1 in 5 children have a tick during their school years. We discussed tics can also include things like shoulder shrugging, facial grimacing, sniffling, excessive throat clearing, and uncontrolled vocalization. I explained that essentially they are brief, sudden and involuntary motor movements and that we do not have a full understanding of the cause. We also discussed that they typically occur around 5 to 10 years of age and mostly resolve on their own within a year. Dad was advised that treatment is not recommended as they do not appear to be bothering Karen and she continues to do well in school and activities. Additionally, we discussed avoiding drawing attention to the tic as it may cause Karen to feel self-conscious and increase the severity of the tic.
- Medical Treatment: None at this time.

Patient Agreements: The patient's parent understands and agrees with the recommended medical treatment plan.
All questions were answered.


[doctor] russell ramirez is a 45 -year-old male with past medical history significant for cad status post prior status post prior rca stent in twenty eighteen hypertension and diabetes mellitus who presents for hospital follow-up after an anterior stemi now status post drug-eluting stent and lad and newly reduced ejection fraction ejection fraction thirty five percent and moderate mitral regurgitation alright russell hi how are you doing today
[patient] hey document i i do n't know i'm doing alright i guess
[doctor] just alright how's it
[patient] well
[doctor] how's it been since you've had your heart attack have you been have you been doing alright
[patient] no i've been seeing you for years since i had my last heart attack in two thousand eighteen but i've been doing pretty good i ca n't believe this happened again i mean i'm doing okay i guess i just feel tired every now and then and but overall i mean i guess i feel pretty well
[doctor] okay good were you able to enjoy the spring weather
[patient] yeah some i mean i'm hoping now that i've had my little procedure that i'll feel better and feel like getting back out and and maybe doing some walking there is some new trails here behind the rex center and maybe get out and walk those trails
[doctor] that will be fine i know you love walking the trails i know you like looking at the flowers because i think you you plant a lot of flowers as well do n't you especially around this time
[patient] yeah i do some gardening around the house
[doctor] yeah
[patient] and you know i really like photography too being able to go out and take nature pictures
[doctor] yeah
[patient] so i'm hoping to be able to go out and do that
[doctor] okay well we'll we'll do what we can here to get you out and going doing all those fun activities again now tell me have you had any chest pain or any shortness of breath
[patient] no not really no chest pain or shortness of breath i've been doing some short walks right around the house so like around the block
[doctor] okay
[patient] but i stay pretty close to the house i've been doing some light housekeeping and i do n't know i seem to be doing okay i think
[doctor] okay alright now tell me are you able to lay flat at night when you sleep or
[patient] well i mean i i never have truly laid flat on my back i've always slept with two pillows which is normal for me
[doctor] okay
[patient] so i mean i guess i really do n't have any troubles with my sleeping
[doctor] okay good how about are your legs swelling up
[patient] nope i've always i always had skinny ankles like like i got dawn knots legs
[doctor] well that's cute were you able to afford your medications and are you taking them as prescribed
[patient] yeah i've been taking my medicine i got pretty good insurance there through the plant and and so the co-pay is n't too bad
[doctor] okay
[patient] and i've been taking them because i do n't want my sense to close up and they told me that that to take them this you know all the time and and i've been taking them since i got out of the hospital
[doctor] okay well very good i'm glad you're doing that good for you russell and and then please keep that up now tell me are you watching your salt intake and trying to change your diet
[patient] yeah so when i was in the hospital they said something about my way my heart pumps now
[doctor] mm-hmm
[patient] it it's it's a little low and i might keep fluid on my legs if i'm not careful
[doctor] right
[patient] and it's gon na be hard because you know i i really do like pizza and and they told me that i'm really gon na have to watch salt and they said that there is a lot of salt and pizza
[doctor] there is a lot of salt and pizza and you know and you're gon na have to be able to avoid all the other salty foods as well so and i know that's hard but it's very important for your heart to be able to function at it's best right and you wan na be able to get out and walk you know walk take those walks again at the park and then you know do your photography so in order to do that we're gon na have to really cut back on those okay
[patient] well
[doctor] alright so why do n't we go ahead and do a quick physical exam on you here i just want to take a look at you your vital signs look good i'm glad to see you're tolerating the medication well i'm gon na go ahead and feel your neck here i do n't appreciate any jugular venous distention and there are no carotid bruits on your heart exam there is a three out of six six systolic ejection murmur it's heard at the left base but that's pretty much the same as last year so we'll continue to monitor that okay let me listen to your lungs here real quick russell your lungs are clear so good good and your extremities i do n't see any swelling or edema on your right radial artery the cath site there is clean and it's dry and intact and i do n't see any hematoma so that's good and there is a palpable rra pulse so russell i did review the results of your ekg which showed normal sinus rhythm good r wave progression and evolutionary changes which are anticipated so let's go ahead and talk about my assessment plan for you for your first diagnosis of coronary artery disease we are gon na have you continue your your aspirin eighty one milligrams daily and brilinta ninety milligrams twice daily and we're gon na have you continue on that high dose statin that atorvastatin you might call it lipitor eighty milligrams daily and then also continue on that toprol fifty milligrams daily okay and i'm also going to refer you to cardiac rehab so for you to get some education about your heart and also give you the confidence to get back exercising regularly now i know patients love the cardiac rehab program i think you will do well does that sound good to you
[patient] that sounds good document
[doctor] alright so for your second diagnosis here the newly reduced left ventricular dysfunction and moderate mitral regurgitation i think your pumping function will improve in time you know they got you to the lab quickly so i think that heart muscle is just stunned and you're very compliant you're very good with your medications and following through with those so i think it will recover so that said i want you to go ahead and continue continue your lisinopril twenty milligrams a day i do n't think you need a diuretic at this time but i do want to add aldactone twelve . five milligrams daily and then you'll need to get labs next week okay and then we're gon na repeat another echocardiogram echocardiocardiogram in about two months
[patient] okay
[doctor] okay and then for your hypertension your third diagnosis of hypertension i want your to take your blood pressure just like you would you know every so often and then because your blood pressures actually seem fine at this time so we will continue to monitor that and i think you will tolerate the aldactone well as well
[patient] alright sounds good document
[doctor] okay well you take care and you have a good evening
[patient] yeah you too
[doctor] bye

CHIEF COMPLAINT

Hospital follow-up after an anterior STEMI.

MEDICAL HISTORY

Patient reports history of CAD status post prior RCA stent in 2018, hypertension, and diabetes mellitus.

SURGICAL HISTORY

Patient reports history of RCA stent in 2018 and most recently underwent drug-eluting stent placement in the LAD.

SOCIAL HISTORY

Patient reports enjoying walking outside, gardening, and nature photography.

MEDICATIONS

Patient reports taking aspirin 81 mg daily, Brilinta 90 mg twice a day, Lipitor 80 mg daily, Toprol 50 mg daily, and lisinopril 20 mg a day.

REVIEW OF SYSTEMS

Constitutional: Reports fatigue. Denies changes in sleep.
Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Musculoskeletal: Denies lower extremity swelling.

VITALS

Vital signs look good today.

PHYSICAL EXAM

Neck
- General Examination: No carotid bruits.

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
- Auscultation of Heart: Grade 3/6 systolic ejection murmur, heard at the left base.

Musculoskeletal
- Examination of the right upper extremity reveals no swelling or edema on the right radial artery. Cath site is clean, dry, and intact. No hematoma. Palpable right radial artery pulse.

RESULTS

Electrocardiogram is reviewed and revealed normal sinus rhythm with good R wave progression and evolutionary changes, which are anticipated.

ASSESSMENT AND PLAN

1. Coronary artery disease.
- Medical Reasoning: The patient's exam is consistent with coronary artery disease.
- Patient Education and Counseling: We discussed that he should continue to watch his diet and salt intake. We also discussed that the cardiac rehab should help with his confidence with exercising regularly and for his education.
- Medical Treatment: Continue taking aspirin 81 mg daily Continue taking Brilinta 90 mg twice a day. Continue taking Lipitor 80 mg daily. Continue taking Toprol 50 mg daily. I will refer him to cardiac rehab.

2. Newly reduced left ventricular dysfunction and moderate mitral regurgitation.
- Medical Reasoning: The patient's physical exam is consistent with this diagnosis.
- Patient Education and Counseling: We discussed that his pumping function should improve in time. We also discussed that since he is compliant with his medications and presented to the cardiac cath lab quickly, he should recover. I advised the patient that he does not need to start a diuretic at this time.
- Medical Treatment: Continue taking lisinopril 20 mg a day. Prescription for Aldactone 12.5 mg daily provided. Order for labs provided. Repeat echocardiogram ordered to be completed in 2 months.

3. Hypertension.
- Medical Reasoning: This seems stable at this time.
- Medical Treatment: Continue home blood pressure monitoring.

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


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

CHIEF COMPLAINT

Sore throat.

MEDICAL HISTORY

Patient reports history of hypertension and diabetes.

SOCIAL HISTORY

Patient reports working as a cashier in a supermarket. She enjoys drinking wine.

MEDICATIONS

Patient reports taking lisinopril 20 mg daily, multi-vitamin, vitamin D, and metformin 1000 mg twice daily.

REVIEW OF SYSTEMS

Constitutional: Reports fever, chills, and profuse sweating.
HENT: Reports sore throat, dysphagia, tonsil swelling, and congestion.
Gastrointestinal: Denies abdominal symptoms.

VITALS

Temperature: 100.4 degrees F.
Blood pressure: 132/80 mm Hg.
Heart rate: 84 BPM.

PHYSICAL EXAM

Head and Face
- Examination: No pain to palpation of the frontal or maxillary sinuses.

Ears, Nose, Mouth, and Throat
- Examination of Nose: Edema and erythema of the nasal turbinates noted bilaterally with associated clear discharge.
- Examination of Throat: Erythema and edema of the peritonsillar space with exudates present bilaterally. The uvula is midline.

Neck
- General Examination: No thyromegaly, but there is some cervical lymphadenopathy on the right side.

Respiratory
- Auscultation of Lungs: Coarse rhonchi at the bases that clear with cough.

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

RESULTS

Rapid COVID-19 test performed today in office is negative.

ASSESSMENT AND PLAN

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

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

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

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


[doctor] okay hi andrea well i
[patient] hello
[doctor] i understand you're you've come in with some right knee pain can you tell me about it what's going on
[patient] it it's not the right knee it's the left knee
[doctor] okay the left knee
[patient] and it just happens occasionally less than once a day when i'm walking all of a sudden it is kind of like gives out and i think here i'm going to fall but i usually catch myself so lot of times i have to hold a grocery cart and that helps a lot so it comes and goes and it it passes just about as quickly as it comes i do n't know what it is whether i stepped wrong or i just do n't know
[doctor] okay well so where does it hurt like in on the inside or the outside or
[patient] internally and it it just the whole kneecap fades
[doctor] okay well did you hear or feel a pop at any point
[patient] no
[doctor] okay
[patient] like that
[doctor] have you ever had any type of injury to that knee i mean did you fall or bump it against something or
[patient] no not that i can recall
[doctor] okay and have is it painful have you taken anything for for pain
[patient] no because it does n't last that long
[doctor] okay
[patient] it just like i said it just it goes about as fast as i came in
[doctor] so is it interfering with your just things you like to do and
[patient] hmmm no not really
[doctor] so i know you said that you like to do a lot of travel
[patient] yeah i've got a trip planned here in the next month or so and we are going down to columbus georgia to a a lion's club function and probably be doing a lot of walking there and they got some line dances planned and i do n't think i will be able to participate in that because of the knee
[doctor] is that where you would be kicking your leg out or something
[patient] no it's do n't you know what line dancing is like dancing in theories of fairly fast moves but it's mostly sideways motion
[doctor] and is and that you think that's when your knee might give out then or just not gon na take the chance
[patient] not gon na take the chance
[doctor] okay yeah that sounds like a good idea have you thought about even having a a cane just in case or do you think that's does that happen often enough
[patient] wrap it i would n't be able to keep track of it so no no pain
[doctor] okay okay well so since you're in how about your blood pressure how how is it doing and have you been taking your blood pressures at home like we talked about
[patient] yes they are doing fine still about the same
[doctor] so
[patient] correct that whatever
[doctor] so what has it been running
[patient] i ca n't really remember it's been several days since i took it but i think it runs around one twenty over seventy somewhere along in there
[doctor] okay alright and so what about your medication we have you on some medication for your blood pressure right
[patient] yes i take take them regularly at eight thirty in the morning and eight thirty at night
[doctor] and what is the medication and the dosage that you are taking
[patient] i'm taking a farxiga and amlodipine
[doctor] okay
[patient] and lisinopril and the hydrochlorothiazide so i i ca n't pronounce that one so but those are all small dosage pills
[doctor] that but yeah go ahead
[patient] no that was it i just take them regularly eight thirty in the morning eight thirty at night
[doctor] yeah well that's good i i know you said you set an alarm on your phone to make sure that you get them taken at the right time so that's really good and how are your blood sugars doing how is your diet doing
[patient] my blood sugar has been running a little higher at about one thirty
[doctor] is that in the morning when you're fasting
[patient] yes
[doctor] okay
[patient] and i have been told that sometimes the morning blood sugars are higher for some reason but i do n't know i i do n't really worry about it as long as it does n't get up too extremely high so
[doctor] and are you taking your metformin
[patient] yes yes that's along with the blood pressure medicine morning and night
[doctor] okay alright so are you are you eating like late at night or anything like that
[patient] no we usually eat by six
[doctor] okay okay alright well hopefully we can get you to feeling better okay so i want to do a quick physical exam really check that knee out so your vital signs look good they they look alright your temperature is ninety eight . two your pulse is seventy two respirations are sixteen blood pressure is one twenty two over seventy so that looks fine i'm gon na go ahead and take a listen to your heart and lungs so on your heart exam it's a nice regular rate and rhythm but i appreciate a slight two over six systolic ejection murmur at the left base here on your lung exam your lungs are clear to auscultation bilaterally okay now let's take a quick look at that knee so does it hurt when i press on it
[patient] no
[doctor] okay can you bend your knee and straighten it out
[patient] yes
[doctor] okay i'm gon na do some maneuvers and i'm gon na just gon na call out my findings on this okay on your right knee exam no ecchymosis or edema no effusion no pain to palpation of the of the left medial knee is there any decreased range of motion do you feel you feel like you're you're able to fully move that as you should the same as the other knee
[patient] yeah
[doctor] okay so no decreased range of motion negative varus and valgus test okay and so with your x-rays i reviewed the result of your left knee x-ray which showed no evidence of fracture or bony abnormality so lem me tell you a little bit about my plan so your left knee pain i think you just have some arthritis in that i want to prescribe some meloxicam fifteen milligrams a day we might do some physical therapy for that just to strengthen the muscles around that area and prevent any further problems with that okay and so for your second problem the hypertension so i wan na continue the lisinopril at twenty milligrams a day and order an echocardiogram just to evaluate that heart murmur alright and
[patient] okay
[doctor] for the diabetes mellitus i wan na order a hemoglobin a1c to see if we need to make any adjustments to your metformin and i'm also gon na order a lipid panel okay do you have any questions
[patient] no i do n't think so when will all this take place
[doctor] we will get you scheduled for the echocardiogram i will have my nurse come in and we will get that set up okay

CHIEF COMPLAINT

Left knee pain.

HISTORY OF PRESENT ILLNESS

Andrea Barnes is a 34-year-old female who presents today for evaluation of left knee pain.

The patient has been experiencing intermittent episodes of pain and sudden instability with ambulation. Her pain is localized deep in her patella and occurs less than once daily. Due to the fleeting nature of these episodes, she has not taken medication and simply braces herself until it passes. She denies any trauma or injury, or ever hearing or feeling a pop in the knee. Her symptoms do not interfere with her daily activities and she does not use a cane.

Regarding her hypertension, it has been several days since she last checked her blood pressure at home, but it was approximately 120/70 mmHg at that time. Her current medications include amlodipine, lisinopril, and hydrochlorothiazide, all of which she takes on a regular basis.

In terms of her diabetes, her fasting morning blood glucose levels have been approximately 130 based on home monitoring. This is slightly higher than usual, even though she has been compliant with metformin and Farxiga. She does try to avoid eating late at night.

MEDICAL HISTORY

Patient reports a personal history of hypertension and type 2 diabetes.

SOCIAL HISTORY

Patient likes to travel and is planning a trip to Columbus, Georgia in the next month or so. She is part of the Lion's Club.

MEDICATIONS

Patient reports that she is taking amlodipine, lisinopril 20 mg once daily, hydrochlorothiazide, Metformin, and Farxiga.

REVIEW OF SYSTEMS

Musculoskeletal: Reports left knee pain and instability,

VITALS

Temperature: 98.2 degrees F
Heart rate: 72 bpm
Respirations: 16
Blood pressure: 122/70 mmHg

PHYSICAL EXAM

MSK: Examination of the right knee: No ecchymosis or edema. No effusion. No pain with palpation.
Examination of the left knee: Full range of motion. Negative varus and valgus stress test.

RESULTS

X-rays were obtained and reviewed today. These reveal no evidence of fracture or bony abnormality.

ASSESSMENT

1. Left knee pain.
2. Hypertension.
3. Diabetes mellitus type 2.

PLAN

After reviewing the patients x-rays, I believe there is some arthritis in the knee. I'm going to prescribe meloxicam 15 mg once daily. We can consider physical therapy to strengthen the muscles around the area to prevent any further issues.

Her hypertension is well controlled with her current medication regimen. She can continue with lisinopril 20 mg once daily. I'm also going to order an echocardiogram for further evaluation of the murmur heard on exam.

She has been compliant with metformin as prescribed, but her blood glucose levels have been slightly elevated recently. I'm going to order a lipid panel, as well as a hemoglobin A1c to determine if any adjustments need to be made to her dose of metformin.


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

CHIEF COMPLAINT

Emergency department follow up.

MEDICAL HISTORY

Patient reports history of hypertension.

MEDICATIONS

Patient reports taking Bumex 2 mg once daily, Cozaar 100 mg daily, and Norvasc 5 mg once daily.

REVIEW OF SYSTEMS

Constitutional: Denies sleep disturbance.
Cardiovascular: Denies chest pain.
Respiratory: Denies dyspnea.
Genitourinary: Reports urinary incontinence in the setting of diuretic medication.

VITALS

Blood Pressure: 128/72 mmHg
Temperature: 98.7 degrees F
Heart Rate: 72 bpm
Oxygen Saturation: 96%

PHYSICAL EXAM

Neck
- General Examination: No jugular venous distention.

Cardiovascular
- Auscultation of Heart: Stable 2/6 systolic ejection murmur.

Musculoskeletal
- Examination: Trace lower extremity edema.

RESULTS

Echocardiogram reveals a preserved ejection fraction of 55%, abnormal diastolic filling, and mild-to-moderate mitral regurgitation.

ASSESSMENT AND PLAN

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

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

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

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

INSTRUCTIONS

The patient will follow up in 3 months.


[doctor] hi virginia how are you today what brings you in
[patient] i'm doing alright i started seeing this new pcp last year and you know she has been doing a lot of changes to my medication and making sure everything is up to date and she my noticed that my blood pressure has been quite high so she added to medications but and but i you know i've been taking them i've been really good and i i before i was n't but now i am and we're still having a hard time controlling my blood pressure so she thought it would be a good idea for me to see you especially since she noted some on my last blood work she said something about my kidneys
[doctor] okay yeah so okay let's before i dive into a lot of that tell me a little bit about how you've been feeling
[patient] i would say you know most of the days i feel fine i'm still busy at work i definitely can tell though when my blood pressure is high
[doctor] okay you measure it at home you you you measure your blood pressure at home
[patient] yeah i she wanted me to get a blood pressure cuff so i did start getting checking my blood pressures probably like a few times a week
[doctor] okay
[patient] and so then i noticed that it has been getting higher the other day was even as high as one seventy over ninety
[doctor] wow
[patient] so i did call my pcp and she increased the meds again
[doctor] yeah okay now i i just have a couple questions about that are you using a an electronic blood pressure recorder or do you have somebody help you at home
[patient] yeah she i have a a electronic one an electronic arm one
[doctor] okay okay yeah that's good that's good and have you ever tried do you go to cvs at all
[patient] yeah i i do but i've noticed like since the pandemic i do n't see the blood pressures anymore
[doctor] okay okay yeah i i thought the one down on main street they i thought they just brought that one back so
[patient] did they
[doctor] yeah
[patient] that's good to know
[doctor] you may wan na check that but okay so that's good but i what i'd like you to do with that is i'd like you to keep a record of them for me for my next visit with you so let's talk a little bit about your diet tell me how how is your diet what what are the what kind of foods do you like what do you eat normally
[patient] alright do you want the honest answer
[doctor] well yeah that would be better
[patient] so i really you know with everything going on i really been trying to get better but i mean during football season it's really difficult i really love watching my games so have a lot of pizza wings subs like i said i've been trying to cut down especially on days where there is no games but it probably could be better
[doctor] okay i think we all can say that but i do wan na just hey i do n't know that if you've tried it or not but there is a new restaurant down on fifth street and it is nothing but solids and i you know when i heard this i was like okay yeah it's just another these solids are absolutely amazing so if you ever get a chance yeah if you ever get a chance try try that i mean i think you would enjoy them because they're salads that they make are just out unbelievable so let me go ahead and i just have a few more questions and i'm gon na just ask these in in order and you just tell me and then we will come back and talk about them do you have any headaches
[patient] really just when my blood pressure gets really high i have some mild headaches but otherwise i do n't have it on a regular basis
[doctor] okay what about chest pain
[patient] no chest pain
[doctor] shortness of breath
[patient] no shortness of breath
[doctor] even with exertion
[patient] even with exertion
[doctor] okay do you have any swelling in your lower extremities at all that you noticed
[patient] not if i'm on my feet for a long time i'll notice a little bit of swelling but otherwise no
[doctor] okay and then a couple other family history questions anybody in the family have kidney disease or significant high blood pressure
[patient] both my parents do have high blood pressure and one of them did have kidney disease
[doctor] okay okay and in the the the form that you filled out when you came in it says that you are on ten milligrams of norvasc daily and carvedilol twenty five milligrams twice a day is those the medicines you're on
[patient] yes i was also on lisinopril before but with the adjustments yeah those are the ones i'm on
[doctor] okay and so here's where i think we are going to go do you take any nonsteroidals like advil or motrin or aleve
[patient] yeah just once in a while for my like any knee pain or back pain that i have but again not like everyday
[doctor] okay and then lastly what kind of alcohol intake do you have you know do you consider how many drinks a week is really what i'm looking for
[patient] i'll have a couple of beers during the week and like one or two on the weekends
[doctor] okay okay so lem me do a quick physical examination so i looked at your vitals when you came in today and your blood pressure it's still high it's one sixty nine over seventy four your heart rate was eighty eight and your oxygenation was ninety eight percent so those are all fairly good except that blood pressure's a little higher than we'd like to see now when i look at your neck i do n't see any jugular vein distention and i'm gon na listen here real quick no i do n't hear any carotid bruits i'm gon na listen to your lungs okay your lungs are clear and let me listen quickly to your heart i do hear that a two over six systolic ejection murmur and we'll we're gon na have to take a little bit look extra look at that that's when i i can hear an extra sound when i'm listening to your heart and you do have a small amount of one plus pitting edema bilaterally now i did so you do have that your diagnosis is uncontrolled hypertension you know and i think you're aware that that's what your your physician's been treating you for and most of the time this cause is is the cause of this is multifactorial it's not that there is just one thing causing it so we may need to be changing your medicine around and i'm gon na talk to your doctor but first thing before we make any more medication changes i want to order some tests first to rule out if there is any specific cause for this so first order will be a renal artery ultrasound and what i'm looking for there is that there is no areas of areas of narrowing in the the blood vessels of your kidneys that would be the cause of your hypertension in addition to that i'm gon na order a you get another urine collection some morning aldosterone levels reining levels and a twenty four hour urine and these things can really show me if there is any problems with your adrenal glands again this is a lot of big words but you know i'm i i'll write this all out for you i want you to decrease your alcohol i know you like those beers but let's bring it down to maybe one a week or two a week just to get those down lower and then your salt intake you need to be very judicious about decreasing that salt intake i'm gon na give you a referral to a nutritionist to discuss those changes for that you need and and they will help you get that cleared up and then finally stop taking any nonsteroidal medicines such as your advil or motrin the only thing i really want to want you taking is tylenol for any pain right now i am gon na prescribe one medicine and that's cardura four milligrams and i want you to take that once a day and that's good to see if that can help us with your blood pressure and then finally three weeks i'd like you to return i want you to record all of your blood pressures that you take over the next three weeks and bring them into the office but most importantly if you can try to take them at the same time everyday that would be beneficial for me any questions for me
[patient] no i i just it's a lot so i i'm hoping this will work and this will get it under control
[doctor] yeah i i think you know this will be you know this we're gon na spend some time together so i'm glad to have you as a patient but you know we got ta try to get this under control and i'm gon na i'll be talking to your pcp just to let them know that you know what my plans are and we'll stay real in sync on treating this as we move forward does that sound like a plan
[patient] that sounds good thank you
[doctor] okay take care i'll talk to you later
[patient] okay alright bye

CHIEF COMPLAINT

High blood pressure.

SOCIAL HISTORY

Patient reports drinking a couple of beers during the week and approximately 1 to 2 on the weekend. She is employed.

FAMILY HISTORY

Patient reports both of her parents have hypertension and one also had kidney disease.

MEDICATIONS

Patient reports taking Norvasc 10 mg daily and carvedilol 25 mg twice daily. She occasionally takes anti-inflammatories.

REVIEW OF SYSTEMS

Cardiovascular: Denies chest pain or dyspnea on exertion.
Respiratory: Denies shortness of breath.
Musculoskeletal: Denies bilateral lower extremity edema.
Neurological: Reports headaches.

VITALS

BP: 169/74.
HR: 88 bpm.
SpO2: 98%.

PHYSICAL EXAM

Neck
- General Examination: No jugular vein distension. No carotid bruits.

Cardiovascular
- Auscultation of Heart: Grade 2/6 systolic ejection murmur.

Musculoskeletal
- Examination: 1+pitting edema in the bilateral lower extremities.

ASSESSMENT AND PLAN

1. Hypertension, uncontrolled.
- Medical Reasoning: The patient's elevated blood pressure is consistent with uncontrolled hypertension.
- Patient Education and Counseling: We discussed the nature of the diagnosis and that this is typically multifactorial. I advised the patient that further testing should reveal additional information. She was encouraged to reduce her intake of alcohol as well as her salt intake. I recommended that she stop taking anti-inflammatories and use Tylenol as needed for pain. We also discussed the importance of home blood pressure monitoring of the next 3 weeks to see if the medication is beneficial.
- Medical Treatment: Renal artery ultrasound ordered. Urine collection, morning aldosterone levels, renal levels, and a 24-hour urine were also ordered. Referral to nutritionist provided. Prescription for Cardura 4 mg once a day provided as well.

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

INSTRUCTIONS

The patient will follow-up in 3 weeks and will bring her blood pressure log with her.


[doctor] good morning carolyn how are you
[patient] i'm doing alright other than this ankle pain i've been having
[doctor] so i see here that you hurt your right ankle can you tell me what happened
[patient] yeah so yesterday i was going to take out the trash and it was quite icy i thought i was doing okay job and i just slipped and and fell and i'm pretty sure i heard a pop
[doctor] okay and you said this happened yesterday correct
[patient] yeah
[doctor] okay and have you been able to walk on it at all
[patient] no i was so initially when i first fell i was unable to walk at on it at all i had a friend that was visiting and so she heard me fall so she helped me inside now today i have been able to put a little bit more weight on it but i'm still limping
[doctor] okay and then what have you been doing for your foot or ankle pain since that happened
[patient] so i like iced it last night and kept it elevated and i also took some ibuprofen last night and this morning before coming in today
[doctor] okay and can you rate your pain for me
[patient] i would say right now it's like a four out of ten
[doctor] okay and does the ibuprofen help with that pain
[patient] it does it does help with the pain
[doctor] okay and when you take your ibuprofen what can you what's your pain level then
[patient] so this so what did i just say four
[doctor] yes ma'am
[patient] four out of ten so four out of ten is with ibuprofen
[doctor] it's with ibuprofen okay what's your pain level without then
[patient] i would say probably a six
[doctor] okay
[patient] i'm sorry it's a six out of ten without ibuprofen and it goes down to like a one with ibuprofen
[doctor] okay alright that that sounds good have you ever injured that foot and ankle before
[patient] you know i've had a lot of injuries to my ankle but i've never hurt this ankle before i just realized an error
[doctor] okay you know and i see here that you have a history of playing sports looks like you played soccer in college and then played a little bit of a inner marrow soccer now
[patient] yeah
[doctor] i'm i'm guessing you probably have n't been able to do that since you hurt your ankle
[patient] no i have not been
[doctor] so did you hear about the new major league soccer stadium and team that's coming to town they opened in the this year actually they built the stadium have you been down there yet
[patient] no i have to get there
[doctor] yeah we are all excited it's going to be a good time well have you experienced any numbness or tingling in that right foot
[patient] no
[doctor] okay so if it's okay with you i would like to do a quick physical exam your vitals look good and everything there looks okay now i'm gon na do a focused exam on your right ankle i do appreciate some ecchymosis or bruising over the lateral malleolus malleolus associated with some edema or swelling of that area you are positive for tenderness to palpation of the anterior lateral soft tissue and now i do n't appreciate any laxity on anterior drawer and inversion stress there is no bony tenderness on palpation to that foot or ankle area now on neurovascular exam of your right foot you have brisk capillary refill of less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch and all of that is consistent with what's present on your left side as well so i did review the results of your of your x-ray the x-ray of your right ankle showed no fracture which is a good thing so now let me talk to you a little bit about my assessment and plan so for the first problem of right ankle pain your symptoms are consistent with a right ankle sprain or i'm sorry right ankle sprain of your lateral ligament complex more specifically your anterior talofibular ligament now this ligament's on the outside of your ankle ankle which got stretched when you fell the best treatment at this time for your sprain is to keep your leg elevated when you're seated and let's continue to ice okay you're gon na be given an air cast which is gon na help stabilize that ankle and i'm also going to prescribe some crutches because i want you to stay off that leg and start walking on it stay off your leg for now and then in a couple of days start walking on it as tolerated do you have any questions or concerns for me
[patient] so how long do you think it'll take to heal
[doctor] so your symptoms should significantly improve over a few weeks but i'd like to follow up with you and see how you're doing let's say i'll see you again in fourteen days now i do want you to go ahead and continue to take nsaids or ibuprofen as needed to help with any pain and that's also gon na help reduce that inflammation and swelling okay
[patient] okay
[doctor] alright i will see you again in two weeks carolyn
[patient] great thank you
[doctor] you're welcome

CHIEF COMPLAINT

Right ankle pain.

HISTORY OF PRESENT ILLNESS

Carolyn Jones is a pleasant 38-year-old female who presents to the clinic today for evaluation of right ankle pain.

The patient sustained an injury to her right ankle when she slipped and fell on ice while taking her garbage out yesterday. This was her first right ankle injury. She believes she heard a pop at the time, but denies any associated numbness or tingling. Initially, she was unable to bear weight on the ankle and required help getting inside; however, she is now able to slightly bear weight but ambulates with an antalgic gait. Ice, elevation, and ibuprofen have been helpful at reducing her pain. She rates her current pain as 4/10, her pain without medication as 6/10, and her pain with medication as 1/10.

Of note, the patient participates in an intramural soccer league but has not been able to play since this injury.

MEDICAL HISTORY

The patient reports that she has had several ankle injuries in the past. This is her first right ankle injury.

SOCIAL HISTORY

The patient reports that she has a history of playing sports. She played soccer in college and is now in an intramural soccer league.

MEDICATIONS

The patient reports that she has been taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right ankle pain.
Neurological: Denies right ankle numbness or tingling.

VITALS

Normal

PHYSICAL EXAM

GAIT: antalgic gait
CV: Brisk capillary refill to less than 3 seconds. Strong dorsalis pedis pulse.
NEURO: Sensation in the right ankle is intact to light touch distally.
MSK: Examination of the right ankle: Ecchymosis over the lateral malleolus associated with trace edema in that area. Tenderness to palpation over the anterolateral soft tissue. No laxity on anterior drawer testing or inversion stress testing. No bony tenderness on palpation of the foot or ankle area. Findings are consistent bilaterally.

RESULTS

X-ray images of the right ankle were obtained and reviewed today. These reveal no evidence of fracture.

ASSESSMENT

Lateral ligament complex sprain, Right ankle.

PLAN

After reviewing the patient's examination and radiographic findings today, her symptoms are consistent with a right ankle sprain of the lateral ligament complex, more specifically the anterior talofibular ligament. We had a lengthy discussion regarding the nature of this injury and the course of treatment. I advised her to keep her leg elevated when she is seated and continue to ice her ankle. She should also continue taking ibuprofen as-needed for pain and inflammation management. She will be placed in an Aircast to help stabilize her ankle, and I am going to order crutches so she can remain non-weight-bearing for the next couple of days. At that point, she can start bearing weight on the ankle as tolerated.

INSTRUCTIONS

The patient will follow up in 2 weeks.


[doctor] hey dylan what's going on so i lift quite a bit of weights i try to stay in shape as much as i can i'm not like normal people i lift heavy weights and my elbow is extremely sore which elbow is it
[patient] actually it's both my elbows but my right elbow is hurting me the most
[doctor] okay and you said you lift a lot of weights
[patient] mm-hmm
[doctor] did you play any sports when you were younger
[patient] not anything you can think of primarily it was basketball baseball and football
[doctor] okay and did your elbows hurt at that time or is this a a new injury
[patient] it's new
[doctor] when did it start
[patient] probably year and a half ago
[doctor] okay on both elbows about a year and a half ago
[patient] yeah
[doctor] okay have you taken anything for the pain
[patient] ibuprofen eight hundred milligrams three times a day
[doctor] okay and does anything make it better or worse
[patient] the more i use my hands or my arms the more it hurts
[doctor] okay have you tried icing
[patient] yes
[doctor] does that give you any relief
[patient] no
[doctor] alright is it the inside or outside of your elbows
[patient] inside
[doctor] inside okay let's just do a quick physical exam here i'll take a look at your right elbow first
[patient] mm-hmm
[doctor] if i bend it this way up does it hurt it's your left does that hurt
[patient] yes
[doctor] how about this
[patient] yes
[doctor] okay so pain with both flexion and extension
[patient] mm-hmm
[doctor] looks like you have little bit of limited range of motion on extension not on flexion though you said it hurts right here on the inside of your elbow
[patient] yes
[doctor] okay so pain on the medial side with palpation
[patient] yes
[doctor] alright how about the outside
[patient] no
[doctor] no pain with palpation outside of the elbow you have do you have normal sensation in your fingers
[patient] i think so
[doctor] yeah
[patient] yeah
[doctor] okay great
[patient] good to go
[doctor] sensation is normal to the touch
[patient] yes
[doctor] pulses equal in all extremities how about the left elbow same thing if i bend it this way does that hurt
[patient] not as much
[doctor] how about this way
[patient] not as much
[doctor] alright so little bit of pain on flexion and extension little bit of limited range of motion on extension of the arm how about if you twist like you're opening a door
[patient] yes
[doctor] okay so some pain with torsion and twisting supination what about pronation
[patient] no
[doctor] no pain with pronation on the right side
[patient] mm-hmm
[doctor] same thing on the left
[patient] yes
[doctor] pain with supination no pain with pronation
[patient] correct
[doctor] alright so dylan it took some x-rays coming in looks like you do n't have any any fractures or any bony misalignment which i expect with this kind of injury i do think that what you have is medial epicondylitis which is
[patient] is that golfer's elbow
[doctor] yes same thing have you been golfing a lot
[patient] well not in the past year and a half i've had this for a long time
[doctor] okay also known as pictures elbow
[patient] well i have n't been pitching either
[doctor] hmmm well in any case what i'm gon na have to do is i'm gon na send you up for mri to take another look at this
[patient] mm-hmm
[doctor] that will be our next step so we'll get you scheduled for the mri probably get you in pretty quick here since we're a private practice
[patient] thank god
[doctor] yeah and once you get the mri i'll know a little bit more what i'd like to do is something called a whole blood transfusion have you heard of that before
[patient] no please tell me remind me
[doctor] yeah it should help with the healing of your elbow it's just a procedure we'll stick a needle in your elbow
[patient] you do a stick needle in my elbow
[doctor] mm-hmm and help with some of the healing of your elbow
[patient] so it's kinda like dry needling then
[doctor] no
[patient] not at all
[doctor] what is it
[patient] is it is that that thing where like you take the blood out of like say my my thigh
[doctor] mm-hmm
[patient] and then you literally inject it into my tendon
[doctor] yes
[patient] that it activates the healing
[doctor] yeah that's exactly what it is
[patient] interesting cool
[doctor] yeah
[patient] maybe i have heard about that
[doctor] we've we've had some really good responses from other patients on it so hopefully i mean that should be a good solution for you since you've been having issues with this
[patient] i'm excited
[doctor] yeah and we can hopefully get you scheduled for that in the next couple of weeks it's not not a major procedure and you should heal in the next two weeks so that wo n't be a problem especially considering that you're expecting a newborn soon we want to make sure you're all healed for that
[patient] wow i did n't even say that
[doctor] i read it in your chart
[patient] man you doctors are good
[doctor] yeah anything else going on today
[patient] just trying to figure out how you're doing
[doctor] very good thank you
[patient] you're welcome
[doctor] nice to see you
[patient] you have a good day

CHIEF COMPLAINT

Bilateral elbow pain, right worse than left.

HISTORY OF PRESENT ILLNESS

Dylan Bennett is a pleasant 53-year-old male who presents to the clinic today for the evaluation of bilateral elbow pain, right worse than left.

The patient has been experiencing bilateral elbow pain, right worse than left, for approximately 1.5 years. His pain is localized to the medial aspect of his elbows and is described as being extremely sore, worse with increased use of his upper extremities. Of note, he utilizes heavy weights for strength training and was very active in sports when he was younger, primarily playing basketball, baseball, and football, but he denies having any pain at that time. Applying ice to the area has not been helpful, but he does use ibuprofen 800 mg 3 times daily.

SOCIAL HISTORY

The patient reports that utilizes heavy weights for strength training. He was also very active in sports when he was younger, primarily playing basketball, baseball, and football.

He is expecting a newborn baby in the near future.

MEDICATIONS

The patient reports that he has been taking ibuprofen 800 mg 3 times daily.

REVIEW OF SYSTEMS

Musculoskeletal: Reports bilateral elbow pain, right worse than left.

PHYSICAL EXAM

CV: Pulses are equal in all extremities.
NEURO: Sensation is normal to light touch distally.
MSK:
Examination of the right elbow: Limited range of motion with extension with pain. Full range of motion with flexion with pain. Pain to palpation along the medial aspect. No pain to palpation on the lateral aspect of the elbow. Pain with supination. No pain with pronation.
Examination of the left elbow: minimal pain with flexion and extension Slight Limited ROM on extension of the arm. Pain with supination. No pain with pronation.

RESULTS

X-ray images of the bilateral elbows were obtained and review in office today. These reveal no evidence of fracture or bony misalignment.

ASSESSMENT

Bilateral medial epicondylitis.

PLAN

After reviewing the patient's examination and radiographic findings today, we had a lengthy discussion in regards to his current symptoms. I want to get an MRI of the bilateral elbows for further evaluation. We discussed the possibility of performing a whole blood transfusion to encourage healing, and the patient is already familiar with this procedure.


[doctor] so barbara i i know you are here for some itchy scalp pain can you tell me a little bit about how you're doing
[patient] yeah it's still quite a problem you know something i've been suffering with for so long now it's still quite itchy and it's really embarrassing too because i'll have dandruff so much like all over me but but i just ca n't stop itching
[doctor] okay when did you first notice this
[patient] i wan na say it's been a while but probably worsening in the past like six months or so
[doctor] okay okay and have you seen ever noticed any rashes either when it first started or intermittently anywhere else
[patient] on my body no not really
[doctor] okay okay just mainly up underneath your on your scalp there uh and i can i can see that man that looks really itchy and scaly have you died your hair recently or used any other chemicals you you know like a new hair spray or gel
[patient] nothing new i mean i do dye my hair but i've been doing that for years now but otherwise i do n't really use a lot of products in my hair
[doctor] yeah i you know it's funny you say that because i keep saying i earned this gray hair and i'm gon na keep it so yeah have you tried any over the counter treatments i know there is a lot out of there something you know like a t gel or any of those other have those helped
[patient] yeah i did that i did head and shoulders i even tried some castor oil and but none of them really seemed to be helping
[doctor] okay okay let's talk about some other symptoms any joint pain fever weight loss
[patient] not that i can recall i've been pretty good otherwise
[doctor] okay good and going back you know to your grandparents has anybody else in the family had similar symptoms that you're aware of
[patient] no well maybe my sister
[doctor] maybe your sister okay
[patient] yeah maybe my sister i mean i know she'll is no one has as bad as i do but she does report like just having a dry scalp
[doctor] okay okay now you know a lot of times we can see this with you know high levels of stress has there been any new mental or emotional stressors at work or at home
[patient] not really i mean it's basically the same things
[doctor] okay yeah i yeah we have a lot of that yes so let me go ahead and and look at this a little closer here the first off i wan na tell you the the vital signs that the my assistant took when you came in your blood pressure is one thirty over sixty eight your heart rate was ninety eight and your respiratory rate was eighteen so those all look good and appear normal and your temperature was ninety seven . seven and that is all normal now when i look at your scalp here i do notice that you have demarcated scaly erythematous plaques and that's just kind of explaining technically what's going on those patches and they're they're in a patchy format they're diffusely present across the back of your skull and that's probably why you you see all that that that white dander you know on your on your your clothes as you go through the day now lem me talk a little bit about my impression and plan i think that you have a scalp psoriasis and let's and here is my thoughts on that what i would like you to use is to use clobetasol that's a zero . zero five percent solution and i want you to use that twice daily on the the affected areas of your scalp so you're just gon na put this on and just kinda gently rub it in now i know to do it twice daily is going to be difficult but if you can do it first thing in the morning when you get up and then before you go to bed you know get a shower and before you go to bed that will be great i want you to continue to use t-gel shampoo that you listed when you first came in that's a very good solution shampoo for that and that will help with controlling a lot of this now there is no cure for this unfortunately and flareups can be unpredictable but we see that you know not a we do n't have a great finger on what causes the flare ups but i'm gon na give you some steroids that will help and we're gon na have to manage that on a ongoing basis but when you get do get a flare up i want you to be using these flare steroid that i give you as we go through that and then i wan na see you back here in three months or sooner if it gets significantly worse do you have any questions for me
[patient] no okay so i'll just use that steroid solution and then just as needed if it's really bad but then otherwise just use the t gel
[doctor] yeah i want it's exactly what i want you to do i want you to use that that solution twice daily when you get that flare but then other than that just continue to use that t-gel shampoo
[patient] alright
[doctor] okay i'm gon na have my nurse come in and get you discharged but i the we will see you again in three months or and again please if it gets worse please do n't hesitate to call me and come in sooner
[patient] alright perfect thank you
[doctor] thank you
[patient] okay bye

CHIEF COMPLAINT

Itchy scalp pain.

REVIEW OF SYSTEMS

Constitutional: Denies fever or weight loss.
HENT: Reports scalp pain Musculoskeletal: Denies joint pain.
Skin: Reports itchy scalp Denies any rashes.

VITALS

BP: 130/68.
HR: 98.
RR:18.
Temperature is 97.7 today.

PHYSICAL EXAM

Integumentary
- Examination: Scalp reveals demarcated scaly, erythematous plaques. They are patchy in format and diffusely present across the back of the skull.

ASSESSMENT AND PLAN

1. Scalp psoriasis.
- Medical Reasoning: The patient presents today with symptoms similar to scalp psoriasis.
- Patient Education and Counseling: Nature of the diagnosis was discussed as well as treatment options. Patient was advised there is no cure for this. Patient was counseled on how to apply clobetasol 0.05%.
- Medical Treatment: Prescription for clobetasol 0.05% solution twice daily provided. Continuing using T/Gel shampoo. Prescription for steroids provided to be used for flare ups.

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

INSTRUCTIONS

The patient will follow-up in 3 months or sooner if her conditions worsen.