[doctor] hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on
[patient] and i've been in a lot of pain it started about i would say probably about three days ago
[doctor] okay
[patient] started having pain on my left back
[doctor] okay
[patient] and since then i continued to have pain it is traveling a little lower it's gotten little low but i definitely have not passed it yet and i'm just in so much pain
[doctor] okay so is the pain that you're having is it constant or does it come and go
[patient] it's constant
[doctor] okay
[patient] all the time i ca n't get comfortable
[doctor] alright are you able to urinate
[patient] i am and this morning i actually started seeing some blood
[doctor] okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes
[patient] i've had it for probably this might be my third time
[doctor] third time alright
[patient] yeah i have n't had one in a while but yeah this is my third time
[doctor] okay so have you noticed any nausea chills fever
[patient] no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous
[doctor] okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain
[patient] yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working
[doctor] okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved
[patient] yeah usually usually about about three four days to pass it yeah
[doctor] right so this is this is the looks like this is the third day
[patient] yeah
[doctor] so we are getting close there
[patient] okay
[doctor] yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff
[patient] i was i have n't been great about taking it but i did get the blood pressure cuff
[doctor] so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running
[patient] like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty
[doctor] okay
[patient] and then the bottom number has been between seventy and eighty okay that i mean that's not too bad i think when you were first diagnosed you were up there in the
[doctor] the one eighties which was really high
[patient] right
[doctor] so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that
[patient] trying my best but doc i really like my french fries
[doctor] yeah
[patient] like
[doctor] we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help
[patient] yeah some help could be helpful okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright
[doctor] so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday
[patient] i have and those those have been pretty good they are like in the low one hundreds
[doctor] okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday
[patient] i do
[doctor] okay
[patient] i do take it
[doctor] that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain
[patient] no chest pain
[doctor] no chest pain are you having any belly pain
[patient] the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain
[doctor] no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt
[patient] yes
[doctor] okay i'm gon na press here on your back is that painful
[patient] yes
[doctor] alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound
[patient] that sounds good and i i just i just want this pain to go away so thank you
[doctor] okay no problem

CHIEF COMPLAINT

Left-sided back pain.

MEDICAL HISTORY

Patient reports history of history of hypertension, diabetes, and kidney stones.

MEDICATIONS

Patient reports taking Tylenol, occasional ibuprofen, Norvasc 2.5 mg daily, and metformin 500 mg daily.

REVIEW OF SYSTEMS

Constitutional: Reports chills and decreased appetite. Denies fever.
Cardiovascular: Denies chest pain.
Gastrointestinal: Reports nausea. Denies abdominal pain.
Genitourinary: Reports hematuria.
Musculoskeletal: Reports left-sided back pain.

VITALS

Blood pressure is slightly elevated, likely due to patient's pain level.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi.

Cardiovascular
- Auscultation of Heart: Grade 2 out of 6 systolic ejection murmur, unchanged.

Gastrointestinal
- Examination of Abdomen: Tenderness to palpation of the abdomen. No rebound or guarding. CVA tenderness present at right flank.

RESULTS

Previous hemoglobin A1c is reviewed at 7.3.

ASSESSMENT AND PLAN

1. Kidney stone.
- Medical Reasoning: Patient presents today with symptoms consistent with kidney stones. She does have a history of kidney stones with this being her third episode.
- Patient Education and Counseling: We discussed the importance of pushing fluids to help facilitate passing the kidney stone.
- Medical Treatment: Prescription for oxycodone 5 mg every 6 to 8 hours as needed for pain was provided today. Tylenol is recommended for breakthrough pain. She will push fluids and has been provided with a urine strainer. Referral to urology was also provided due to her recurrent episodes.

2. Hypertension.
- Medical Reasoning: Patient is currently stable and has not had any elevated readings. Her blood pressure was slightly elevated today, however, this is due to her current pain level.
- Patient Education and Counseling: We discussed the importance of home blood pressure monitoring with the goal of at least 3 times per week. She was also advised on the importance of diet modification with limiting salt to 2300 mg daily.
- Medical Treatment: Continue Norvasc 2.5 mg. Continue with home blood pressure monitoring 3 times per week. Limit salt intake to 2300 mg daily.

3. Diabetes.
- Medical Reasoning: Patient is currently stable and has not had any elevated glucose readings.
- Patient Education and Counseling: We discussed the importance of diet modification.
- Medical treatment: Continue metformin 500 mg daily. Continue with home glucose monitoring before meals. Referral to a dietitian was provided.

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


[doctor] hey mason good to see you today so let's see you here in my notes for evaluation of kidney stones your your pcp said you had some kidney stones so you got a referral over so can you tell me a little bit about that you know what happened when did you first notice them
[patient] yeah it was about you know about a week ago and i was working down in the the barn with the horses and you know i was moving some hay but i developed this real sudden onset of pain in my right back and i thought it initially it was from throwing hay but it i broke out into a sweat i got real nauseated and that's when i went and saw my doctor and he ordered a cat scan and said that i had a kidney stone but you know that's i i've never had that before my father's had them in the past but yeah so that's that's how that all happened
[doctor] okay so you said you had the pain on the right hand side does it move anywhere or radiate
[patient] well when i had it it would it radiated almost down to my groin
[doctor] okay
[patient] not the whole way down but almost to the groin and since then i have n't had any more pain and it's just been right about there
[doctor] okay and is the pain constant or does it come and go
[patient] well when i you know after i found out i had a disk a kidney stone it came a couple times but it did n't last as long no i've been i've been straining my urine they told me to pee in this little cup
[doctor] mm-hmm
[patient] and i've been straining my urine and you know i do n't see anything in there
[doctor] okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual
[patient] no not really not really darker
[doctor] okay so have you had kidney stones before and then you said your father had them but
[patient] i've never had a kidney stone my dad had them a lot but i've never had one
[doctor] okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means
[patient] i have a stroke
[doctor] can you repeat that
[patient] i did i have a stroke
[doctor] no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in the proximal right ureter and that's that duct that classes from your your kidney to down to your bladder there is no evidence of hydronephrosis that would mean that the stone is obstruct obstructing the ureter causing swelling in the kidney so there is there is no evidence of that so let's talk a little bit about my assessment and plan so you do have that kidney stone so right now i'm gon na recommend that we we have you push fluids just to help facilitate you urinating and passing the stone i'm gon na prescribe you some oxycodone five milligrams every six to eight hours for pain and you can continue to take tylenol between that for any breakthrough pain and you already have a strainer so that's good continue to use that and we can see continue that until the stone hasses and i'm also gon na order a bmp and your urinalysis and urine culture just to make sure that everything else is okay with you and based on urinalysis we can see if we need to prescribe you antibiotics see if you have any type of infection i do want to see you back in about one to two weeks and hopefully by that time you you passed the stone but if not we can discuss further treatment lithotripsy it's like a shock wave kinda breaks up that stone it's not it's not that invasive procedure but we can just we can discuss that if it has n't passed in that one to two weeks that sound good
[patient] that sounds perfect dear too
[doctor] alright
[patient] thank you document
[doctor] so i will see you in a week or so and hopefully you've passed that stone and i'll send my nurse in with that prescription
[patient] okay thank you
[doctor] thanks

CHIEF COMPLAINT

Kidney stones.

HISTORY OF PRESENT ILLNESS

Mason Ward is a pleasant 80-year-old male who presents to the clinic today for the evaluation of kidney stones. The patient was referred from his primary care physician. The onset of his pain began 1 week ago when he was in his barn moving hay when he had a sudden onset of right back pain. The patient initially thought his pain was due to throwing hay; however, he broke out into a sweat and became nauseated. He was seen by his primary care physician, who ordered a CT scan and told him that he had a kidney stone. He denies having kidney stones before, but states that his father has a history of kidney stones in the past. He explains that when he had pain, which has now resolved, it would radiate almost to his groin. The patient describes the pain as intermittent after he found out it was a kidney stone. He explains that he has been straining his urine, but has not seen anything. He denies any hematuria.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right back pain.

VITALS

Vitals look good, blood pressure and hear rate are within normal limits. Temperature is within normal limits.

PHYSICAL EXAM

MSK: Examination of the abdomen: No pain with palpation of the abdomen. No rebound or guarding. There is CVA tenderness on the right side.

RESULTS

The CT scan of the abdomen revealed a stone that is measuring 0.5 cm located in the proximal right ureter. There is no evidence of hydronephrosis.

ASSESSMENT

Right kidney stone.

PLAN

We reviewed the patient's CT results in detail today. I have recommended that we treat the patient conservatively. I have prescribed the patient oxycodone 5 mg every 6 to 8 hours for pain. He may continue to take Tylenol between the oxycodone doses for any breakthrough pain. The patient should continue to use the strainer when he urinates until the stone passes. I have also recommended that we obtain a BMP, urinalysis, and urine culture to evaluate for any signs of infection.

INSTRUCTIONS

The patient will follow up with me in 1 to 2 weeks to check on his progress. If his symptoms have not improved, we will discuss further treatment options including lithotripsy.


[doctor] hi jeremy how are you
[patient] i'm really good thank you how are you
[doctor] i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks
[patient] yes
[doctor] going away
[patient] yeah it's been there gosh it's like six or so weeks right now and it's and it's on my right foot and it's just yeah it's just not going away i'm not sure if it maybe even gotten a little worse from when i first noticed it
[doctor] okay and how long did you say it's going on for
[patient] probably about
[doctor] six eight weeks maybe
[patient] okay and do you have any pain in your foot no no no pain at all okay now i know that you're a diabetic and you are on some insulin have your sugars been running okay yeah they have been running
[doctor] okay
[patient] you know on the most part they seem to be running a little higher than normal
[doctor] your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine
[patient] yes it it it definitely was higher than nine
[doctor] okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or
[patient] yeah i was you know i think initially i'm you know i was out in the backyard you know kind of you know doing some work and you know i know i you know i could've stepped on a nail or you know there was some other work but you know i'm always outside so i do n't know if that kind of led to anything or caused anything
[doctor] okay alright and have you had any fever or chills
[patient] no no no fever or chills you know i kinda you know get headaches pretty often i do n't know if that you know i do n't know if that's a stress or but you know always have like the tension headaches in the front
[doctor] okay and do you have do you have neuropathy where you get like numbing and tingling in your feet
[patient] occasionally yeah occasionally especially when it's like colder outside
[doctor] mm-hmm kinda feels like it takes a little longer to
[patient] warm up but yeah i kinda have some sensation in in all my extremities
[doctor] okay alright and then are you are you a smoker or did you smoke
[patient] i did back you know kind of years ago i did but yeah i have n't smoked anything in in good number of years
[doctor] okay alright when did you stop smoking
[patient] couple years ago maybe four or so years ago
[doctor] okay alright and how many packs a day would you smoke
[patient] gosh back then yeah was at least two
[doctor] okay alright how many years did you smoke for like twenty
[patient] yeah at least twenty yeah twenty plus years
[doctor] okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk
[patient] no no no no pain you know just kind of you know it's just i know that it's there
[doctor] okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no
[patient] no no you know it's you know i just kinda feel like i've been just trying to take it easy lately
[doctor] mm-hmm
[patient] but yeah most most of the stuff i've been doing is just kind of hanging around the house
[doctor] okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin
[patient] i am yes yeah i do the baby aspirin every day
[doctor] okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything
[patient] okay and do you have a podiatrist for your yearly foot exams
[doctor] no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here
[patient] no
[doctor] there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help
[patient] any questions
[doctor] yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay
[patient] sure
[doctor] sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay
[patient] okay perfect
[doctor] alright
[patient] perfect thank you so much
[doctor] okay bye

CHIEF COMPLAINT

Right foot ulcer.

HISTORY OF PRESENT ILLNESS

Jeremy Roberts is a 79-year-old male who presents today for evaluation of a right foot ulcer. He reports an ulcer on his right foot has been present for approximately 6 to 8 weeks. He first noticed the ulcer after working outside. There is no associated pain, however, he feels the ulcer may have worsened from when he first noticed it. He denies experiencing any fevers or chills. He does however experience tension headaches quite frequently. He denies any pain in his calves when he walks. At this time the patient does not have a podiatrist for yearly foot exams.

He is a diabetic and takes insulin. His blood sugar has been running higher than normal and his last hemoglobin A1c was higher than 9. Occasionally he will also experience numbness and tingling in his feet, especially with colder weather.

In terms of his heart disease, the patient sustained a heart attack in 2018 and underwent stent placement at the right coronary artery. He is currently taking aspirin 81 mg daily. He denies chest pain or shortness of breath.

MEDICAL HISTORY

Patient reports history of diabetes and heart disease. He sustained a heart attack in 2018.

SURGICAL HISTORY

Patient reports undergoing stent placement at the right coronary artery.

SOCIAL HISTORY

Patient reports he is a former smoker. He previously smoked 2 packs a day for 20 years and was able to stop smoking approximately 4 years ago. Currently he is not very active but he does work around the house.

MEDICATIONS

Patient reports taking aspirin 81 mg daily and insulin.

REVIEW OF SYSTEMS

Constitutional: Denies fevers and chills.
Cardiovascular: Denies chest pain.
Respiratory: Denies dyspnea.
Skin: Patient reports right foot ulcer.
Neurological: Patient reports headaches and numbness and tingling in feet.

VITALS

No fever.
Blood pressure: 127/80
Heart rate: 60s

PHYSICAL EXAM

CV: 2/6 systolic ejection murmur heard at the left base.
RESPIRATORY: Clear to auscultation bilaterally
NECK: No jugular venous distention or carotid bruits
MSK: Examination of the right lower extremity: No palpable dorsalis pedis or posterior tibial pulses. There is a 2 x 3 cm ulcerated lesion on the right lateral foot near the 5th metacarpal metatarsophalangeal joint. No associated cellulitis. No pain to palpation of the right foot. There is associated granulation tissue and some slight purulent discharge from the wound.

ASSESSMENT

1. Non-healing ulcer, right foot
2. Diabetes
3. Coronary artery disease

PLAN

After reviewing the patient's examination findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his right foot ulcer is fairly sizable and will require wound care. I advised him that the ulcer does not appear to be healing and that further studies will be needed to assess if he has adequate blood supply to heal his foot wound. He was advised that due to his diabetes it is possible surgical intervention such as stent placement or bypass surgery may be required to improve his blood supply. I also advised him that I believe we will be able to heal his wound. At this time, I have recommended continued wound care and for him to also continue taking aspirin 81 mg daily. We will order an arterial ultrasound of the lower extremities. He will also be referred to podiatry for a consult.

Regarding his diabetes, this appears to be unstable as the patient reports his last hemoglobin a1c was greater than 9 and is now experiencing a non-healing right foot ulcer. We discussed the importance of blood sugar control as this will impact his wound healing. At this time, I have recommended that he follow-up with his primary care physician for further care.

The patient's coronary artery disease is currently stable. It is recommended that he continue to take his statin as prescribed. I will contact his cardiologist for medical clearance should surgical intervention be required for his non-healing right foot ulcer.


[doctor] so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you
[patient] sure i've been having some back pain on my right side it's been lasting for about a week now
[doctor] okay
[patient] and i also started to see some blood in my urine
[doctor] okay so on the right side so does that pain does it move anywhere or is it just kinda stay in that that one area
[patient] yeah it's moved down a little bit on to my right lower side a little bit
[doctor] side okay so how would you describe the pain is it constant or is does it come and go
[patient] it's pretty constant
[doctor] okay did you notice any pain when you're urinating i know i know you say you you saw you see blood but any pain with that
[patient] no no real pain when i'm when i'm peeing at all
[doctor] okay so have you taken anything i know have you tried like azo or any of that to
[patient] i took some ibuprofen that helped a little bit
[doctor] okay
[patient] but it still hurts even with ibuprofen
[doctor] alright have you noticed any nausea vomiting fever chills
[patient] i have n't thrown up but i felt a little bit nauseated
[doctor] little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but
[patient] yeah my my dad had kidney stones i think he has passed a couple of them i'm not quite sure
[doctor] alright and have you had any in the past or is this your first one
[patient] this is my first time i've never had this before
[doctor] okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that
[patient] yeah yeah i had some pain over the weekend i saw my pediatrician this morning so they sent me over here they were concerned that i might have a kidney stone
[doctor] okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain
[patient] not so much but i i got to participate a little bit i opened some eggs i just did n't go run around and find them
[doctor] okay well i i'm lucky enough my friends had an adult easter hag hunt for me and so i was able to find a couple eggs yesterday myself so i i'm glad you were able to get a few of them alright so let's do that that physical exam on you so your vitals look good you do n't have any fever your blood pressure heart rate is fine so when i press here on your belly does that hurt
[patient] a little bit yeah
[doctor] a little bit alright so on your exam of your abdomen there is mild pain and tenderness to palpation of the abdomen there's no rebound or guarding there is cva located near your flank tenderness on the right so that means that everything looks good but you do have what seems to be some inflammation of your kidney okay so we we were able to get a ct of your your side and it showed that you do have a stone measuring point five centimeters in size and it's located in the proximal right ureter and so that's that duck that passes from your kidney to your bladder alright i do n't see any evidence of hydronephrosis so that means that there's not obstructing ureter causing swelling in your kidney which is which is pretty good so let's talk a little bit about my assessment and plan so you do have that kidney stone on the right so what i'm recommending is i want you to push fluids just to help facilitate you passing that stone alright have you been taking in have you been drinking enough water do you think so far
[patient] probably not enough i drink some but
[doctor] okay yeah i i want you to to drink try drink as much as possible just to see if we can get you hydrated and pass the stone what i'm gon na do is i'm gon na prescribe you ibuprofen eight hundred milligrams you can take that as needed for pain i know you said you were in that much pain just in case it does start to move you're in pain i want you to take the ibuprofen i'm also gon na give you a strainer for you to strain your pee so we can see you wan na know when that that stone does pass gon na order a bmp and a urinalysis and a urine culture and based on what the urinalysis shows we can decide if i can decide if i need to put you on antibiotics if you do have an infection of some kind and i wan na see you back in about a week to two weeks and if you're still having symptoms we can discuss further treatment such as a lithotripsy and it's it's a mainly minimally invasive procedure where we use shock waves to try to break up that stone but otherwise do you have any other questions for me
[patient] no i do n't think so
[doctor] alright so we will see you back in a week or two and i'll have my nurse come in with that prescription and hopefully with all the treatment you'll be able to pass the stone okay alright

HISTORY OF PRESENT ILLNESS

Anna Diaz is a pleasant 29-year-old female who presents to the clinic today for the evaluation of right-sided back pain.

For approximately 1 week, the patient has been experiencing constant right-sided back pain that radiates down to her lower right side, as well as hematuria and nausea. Her primary care physician was concerned for possible kidney stones and subsequently referred her here for further evaluation. She denies any pain with urination or vomiting, but admits that she has likely not been drinking enough water. The only treatment she has tried so far is ibuprofen with minimal pain relief. Although she denies any personal history of kidney stones prior to this occurrence, she explains that her father has had kidney stones in the past.

REVIEW OF SYSTEMS

Constitutional: Negative for fever.
Gastrointestinal: Positive for nausea. Negative for vomiting.
Genitourinary: Positive for hematuria

VITALS

Vitals are normal.
Blood pressure is normal.
Heart rate is normal.

PHYSICAL EXAM

GI/GU: Mild pain and tenderness to palpation of the abdomen. No rebound or guarding. There is CVA located near her flank with tenderness on the right.

RESULTS

CT scan of the abdomen was reviewed today and revealed a kidney stone measuring 0.5 cm in size, located in the proximal right ureter. There is no evidence of hydronephrosis.

ASSESSMENT

Kidney stone, right side.

PLAN

After reviewing the patient's examination and CT results, I discussed the findings with the patient. The CT scan revealed a 0.5 cm kidney stone in the proximal right ureter. I advised her to drink plenty of fluids, as much as possible, to help facilitate passing of the stone. She was provided with a urine strainer so she can see if and when the stone passes. Given that over-the-counter ibuprofen is not providing significant relief, we will send in a prescription for ibuprofen 800 mg to help with her pain. I'm also going to order a BMP, urinalysis, and a urine culture for further evaluation. Depending on the results of the urinalysis, we may need to start her on antibiotics. I want to see her back in 2 weeks. If she is still symptomatic at that time, we may need to consider further treatment such as a lithotripsy. This procedure was explained to the patient.

INSTRUCTIONS

Follow up in 2 weeks.


[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.


[doctor] hey elijah how are you
[patient] i'm doing okay
[doctor] so i see here that your primary care provider sent you over it looks like you were doing some yard work yesterday and dropped a landscape brick on your foot can what so what's going on with your right foot today
[patient] it's a little sore today but you know i hurt my foot before but this is the first time where i'm actually being seen for it
[doctor] okay so you say you've injured your right foot before tell me a little bit about that injury
[patient] twenty years ago i broke my ankle i had to put in a cast but that seems to be okay but you know sometimes it'll give me trouble once in a while it feels a little sore it swells up at times
[doctor] okay
[patient] and my other ankle too is sore sometimes and i've had surgery for that too and you know one of those things where you know it might give out once in a while but i'm not sure that's related to what the you know break dropping on my foot but you know either way my foot's a little sore
[doctor] okay alright so when you dropped that brick on your foot were you able to get up and keep working or did you have to get off your you know not stop weightbearing and and get off that foot can you tell me a little bit about after the traumatic incident
[patient] i you know it was a little sore i called a few names you know god damn why is this in my foot but you know i kept working putting it around a little bit but now it's got swollen so i got to see my doctor he told me i had to go see you here i am so tell me what's going on with it
[doctor] so what have you been doing for the pain since the initial insult
[patient] lucken it up
[doctor] okay have you taken any medications safe for example tylenol or ibuprofen for the pain
[patient] no i feel like taking the medicine
[doctor] okay and then just out of curiosity you said you were doing some landscaping have you been over to landscapes warehouse new here in town my wife and i were just over there this last weekend and picked up a whole bunch of stuff you had a chance to make it over there yet
[patient] no not yet i heard about it though i might have to make a trip once my foot heals
[doctor] alright that sounds good now just out of curiosity can you rate your pain for me right now zero being none ten being the worst pain you've ever been in your life
[patient] eleven out of ten
[doctor] okay and then have you experienced any numbness or tingling of that foot since the incident
[patient] yeah the whole foot is numb
[doctor] okay
[patient] but been now for a long time
[doctor] okay i'm gon na do a quick physical exam now your vitals look good and i would like to do a focused exam of your right foot the there is some bruising on the bottom part of your foot and on the top part as well and i do appreciate the associated swelling and i also recognize that you do have tenderness to palpation for midfoot now for your neurovascular exam of your right foot your capillary refill is brisk in less than three seconds i do note a strong bounding dorsalis pedis pulse with motor and sensation is intact for that foot i also like to call out the fact that it matches bilaterally which is important i'm gon na go ahead and review the diagnostic imaging results so we did a x-ray of that right foot and i do notice dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and presence of bony fragments so let me tell you a little bit about my assessment and plan now your right foot pain is due to a lisfranc fracture which is a fracture to your second metatarsal bone and the top of your foot this is where the metatarsals meet those cuboids okay so it where the bones come together in your foot now there are a lot of ligaments in your foot so i do want to order an mri just to assess if there is any injuries to those ligaments now based on your exam and looking at the x-ray you're most likely going to need surgery now the reason why this is important is if we have poor bone alignment or ligament healing you can this can lead to losing the arch in your foot you could becoming flat-footed and also developing arthritis now what's gon na be key here is the surgery is going to allow those bones and ligaments to heal properly we are going to put them back into place using plates and screws now the key thing is going to be it's going to be outpatient surgery so it's going to be same day i'll see you in the morning and then you'll be discharged home that evening and we will do a follow-up i wan na see you in twenty four hours post procedure but then i'll see you again in two weeks you're gon na be in a cast and i'm gon na have you use crutches you're not gon na be able to weight-bear on that foot for six to eight weeks what we'll do is we'll advance your ambulating gradually based on how you heal and based on how you tolerate the procedure i know i have covered a lot of material quickly but this is really gon na be the best course of action for you to have a good outcome now do you have any questions come answers concerns before i have the nurse come in finish the paperwork and get you set up for your procedure which we are going to do tomorrow if you're agreeable to that
[patient] what about putting in a cast can i just stay in the cast
[doctor] you could but what we found is the best outcome is aligning those bones with plates and screws to make sure that they heal properly so you have the best outcome possible
[patient] so if the surgery is going to be tomorrow when am i going to get my mri
[doctor] so what what we will do is the good news is we have an outpatient mri facility downstairs and i'm going to send the order down and we'll get you your mri this afternoon
[patient] can i think about it and we have some time
[doctor] sure
[patient] okay
[doctor] alright thanks elijah

CHIEF COMPLAINT

Right foot pain.

HISTORY OF PRESENT ILLNESS

Elijah Reyes is a pleasant 45-year-old male who presents to the clinic today for the evaluation of right foot pain. The patient was referred by his primary care physician. He sustained an injury yesterday when he dropped a landscape brick on his right foot while doing yard work. He was able to get up and continue working after the injury. He rates his pain level as an 11 out of 10. The patient also reports numbness in his entire right foot, which has been present for a long time. The patient denies taking any medication for pain.

The patient reports he fractured his right ankle 20 years ago. He received non-operative treatment with casting. He has experienced intermittent soreness and swelling in his right ankle since then.

The patient reports surgical history of his left ankle. He continues to experience soreness and occasional giving way of the left ankle.

MEDICAL HISTORY

Patient reports history of a right ankle fracture 20 years ago.

SURGICAL HISTORY

Patient reports history of left ankle surgery.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right foot pain, right ankle soreness and swelling, and left ankle soreness and instability.
Neurological: Reports right foot numbness.

VITALS

All vital signs are within the normal limits.

PHYSICAL EXAM

CV: Capillary refill is brisk in less than 3 seconds in the right foot. Strong bounding dorsalis pedis pulse.
NEURO: Normal sensation. Right foot motor and sensation are intact and equal to the contralateral side.
MSK: Examination of the right foot: Bruising on the plantar and dorsal aspects of the foot. I do appreciate associated swelling. Tenderness to palpation over the midfoot.

RESULTS

An x-ray of the right foot was obtained and reviewed today. It demonstrates dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases and presence of bony fragments.

ASSESSMENT

Right foot pain, due to a Lisfranc fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding his current symptoms. We discussed treatment options and I have recommended that we proceed with a right foot ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I advised him that this procedure will be performed in an outpatient setting and he will be discharged home that same evening. He will then follow up with me 24 hours post procedure, and again 2 weeks later. I explained that he will be placed in a cast and will remain non-weight-bearing for 6 to 8 weeks. He will use crutches while ambulating and we will advance his weight-bearing gradually based on how he tolerates the procedure.

I have also recommended that we obtain an MRI of the right foot to further assess the ligaments. I explained to him that if he has poor bone alignment or ligament healing, this can lead to losing the arch in his foot causing pes planus and developing arthritis. I will send an order to the outpatient MRI facility downstairs for him to obtain the MRI this afternoon.

The patient wishes to think over his options before proceeding with the operation.


[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.


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

CHIEF COMPLAINT

Recurrent lung infections.

SOCIAL HISTORY

Patient reports he is a farmer. He denies smoking or living with anyone who smokes.

ALLERGIES

Patient denies history of seasonal allergies.

REVIEW OF SYSTEMS

Constitutional: Reports low-grade fever.
Respiratory: Reports shortness of breath and productive cough.

VITALS

Respiratory rate: 20 breaths per minute.
Pulse oxygenation: 99 percent on room air.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Some fine rales were noted.

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

Musculoskeletal
- Examination: No clubbing.

RESULTS

X-ray of the chest was reviewed today and shows some round glass opacities.

ASSESSMENT AND PLAN

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

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


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

CHIEF COMPLAINT

Right great toe pain.

HISTORY OF PRESENT ILLNESS

Joseph Walker is a pleasant 58-year-old male who presents to the clinic today for the evaluation of right great toe pain. The onset of his pain began 2 weeks ago, however it worsened last week. He noticed the pain worsening when he was at a trade show convention and he could not ambulate as he was forced to stand there as the pain was there the whole time. He denies any specific injury. The patient describes his pain usually as throbbing and burning, but notes it occasionally changes to sharp, stabbing pain especially with movement or prolonged ambulation. His symptoms also include redness to the right great toe. The patient states that he has been ambulating on his heel to keep his toe from bending. He reports that his pain is present even with the slightest of pressure, which he notes is worse at night when his sheet is touching his right toe. He adds that he has been taking 2 ibuprofen per day, which does not provide him with relief.

SOCIAL HISTORY

Patient reports that he likes to bicycle ride.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right great toe pain.
Skin: Reports redness.

PHYSICAL EXAM

MSK: Examination of the right great toe reveals 10 degrees of plantar flexion with pain. Pain to palpation of the right great toe, between the big toe and 2nd toe. Palpated a bone spur on the right great toe.

RESULTS

X-ray of the right great toe taken today in office reveals a large bone spur on the anterior aspect of the right great toe joint. There is a loss of cartilage with some arthritis present.

ASSESSMENT

Right foot hallux rigidus.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays revealed hallux rigidus. We discussed treatment options for this and I have recommended that we begin with conservative treatment in the form of custom orthotics. I have also prescribed the patient meloxicam once a day to treat the pain. The patient was instructed to discontinue use and contact the office if gastrointestinal issues develop. I advised the patient that I want him to continue his regular activities.

INSTRUCTIONS

The patient will follow up with me in 2 weeks to check on his progress. If his pain does not improve with the orthotics, I will recommend a cortisone injection or surgical intervention.


[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] okay
[patient] good morning
[doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it
[patient] sure absolutely what can i help you with today
[doctor] so you know i've been dealing with my asthma and like i tried to join sports but it's really kind of it's getting hard you know and i i i just wonder if there's something that can be done because i really do like playing water polo
[patient] but i'm having difficulty breathing sometimes i've had to like you know stop matches and sit on the side just to kind of like catch my breath and use my inhaler so i was wondering if there was something we could do about it
[doctor] and then like i'm kind of a little bit worried i think my mood is getting a little a little worrisome and i i wanted to explore like what my options were
[patient] okay let's talk about the asthma first so what inhaler are you using now
[doctor] i have an albuterol inhaler
[patient] okay and when when you're having trouble it's usually just around sports that is it keeping you up at night
[doctor] so i do n't really like wake up at night a lot typically like it's sports like you know if i'm doing anything like crazy aerobic or like running or anything i do notice that if any if i'm around smoke i do start coughing a little bit but most of the time it's sports
[patient] okay and can you describe a little bit for me what happens
[doctor] i start to yeah no so i start to feel like there is like some phlegm building up in my in my throat and i start coughing like my chest gets tight i start wheezing and i just have to sit down or else i'm gon na get like lightheaded too
[patient] okay and then when you use your inhaler
[doctor] mm-hmm
[patient] does it does it alleviate the problem
[doctor] so yeah it helps with that like phlegm feeling you know but i still i still have to sit down you know and like breathe and then the thing that i hate about that inhaler is i start getting like shaky is that supposed to be happening
[patient] yes that is unfortunately normal and a side effect with the inhaler
[doctor] okay
[patient] so you use you're using two puffs of the inhaler
[doctor] mm-hmm
[patient] for the symptoms
[doctor] yes
[patient] and then you sit down and does it does it get better within about fifteen minutes or so
[doctor] yeah yeah it does but you know i had to like step out of the the pool to make that happen i'm hoping that there is something else we can do okay have you ever taken any daily medications for your asthma an inhaler or singulair or anything like that no i i just use my inhaler whenever i have an attack
[patient] okay so that's something we might wan na consider but how often is it happening
[doctor] pretty much every time i do any kind of aerobic workout
[patient] okay and outside of physical activity you're not having any problems
[doctor] yeah there's that part where like if i'm around somebody who has been smoking a lot or is currently smoking but i usually just step away i do n't even like to be around them you know that makes sense
[patient] alright well we will look at that tell me about the mood issues you are having
[doctor] yeah so one of the reasons i got into like trying to get into sports is like i feel like you know you you feel a lot more energized and a lot you know happier but like lately i've just been kinda stressed out you know like i have i have like sats that i need to study for i've got like all these ap classes you know there's just it i feel like there's a lot of pressure and you know like i get it but there are times where i'm just like really down and i i do n't really know what else i can do
[patient] okay that makes sense any any difficulty with focusing or you're having difficulty retaining information or is it more feeling sad not having motivation
[doctor] so i think it's like a lot of sadness a lot of like you know i do n't really i kinda feel like you know i do n't really like want to do anything you know my friends will go out and i'll just be like i'd rather be at home i am really tired a lot too
[patient] okay alright well let me let me go ahead and check you out
[doctor] mm-hmm
[patient] and then we can talk a little bit more
[doctor] okay
[patient] i'm gon na take a listen to your heart and lungs
[doctor] mm-hmm
[patient] and everything sounds good
[doctor] let me take a look at your eyes
[patient] mm-hmm and in your ears everything looks okay have you had any problems with allergies you have seasonal allergies or anything like that
[doctor] yeah i think so yeah
[patient] i do see just a little bit of fluid in the ears
[doctor] mm-hmm
[patient] and i'm gon na look in your mouth too
[doctor] okay
[patient] and throat looks fine no tonsils
[doctor] mm-hmm
[patient] lem me go ahead and have you lay back on the table and i'll take a listen to your stomach
[doctor] okay
[patient] everything sounds okay i'm gon na feel around just to make sure everything feels normal
[doctor] mm-hmm
[patient] everything feels fine and i'm gon na check reflexes and they're all normal
[doctor] awesome
[patient] it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair
[doctor] mm-hmm
[patient] and start with that once you are on that daily and you can continue to use the albuterol inhaler those side effects unfortunately you're right it's it's just one of the expected side effects with an albuterol inhaler i would recommend just what you're doing just sit down for a little bit after you take it
[doctor] and we will get you started on the singulair probably within about a month you should see a difference so i will have you come back in about six weeks and follow up and see how you're doing with that
[patient] in terms of the mood is this new for you
[doctor] yeah i think so like when i started this year
[patient] and it sounds like related to school expectations and the stress with saps and all of that
[doctor] yeah
[patient] okay let's consider having you start seeing a therapist i think that would be a good place to start
[doctor] mm-hmm
[patient] and we will do some screening questionnaires and and then follow up in a couple weeks on that too
[doctor] okay alright sounds like a plan okay
[patient] thank you

CHIEF COMPLAINT

Asthma.

MEDICAL HISTORY

Patient reports history of asthma.

SURGICAL HISTORY

Patient reports history of tonsillectomy.

SOCIAL HISTORY

Patient reports she is a student and enjoys playing water polo as well as being active with aerobics and running.

ALLERGIES

Patient reports history of seasonal allergies.

MEDICATIONS

Patient reports using an albuterol inhaler, 2 puffs as needed.

REVIEW OF SYSTEMS

Constitutional: Reports fatigue.
Respiratory: Reports shortness of breath.
Psychiatric: Reports mood changes.

PHYSICAL EXAM

Ears, Nose, Mouth, and Throat
- Examination of Ears: Mild fluid in ears.
- Examination of Mouth: Normal.
- Examination of Throat: Tonsils have been previously removed.

Gastrointestinal
- Auscultation: Bowel sounds normal in all 4 quadrants.

Integumentary
- Examination: No rash or lesions. Normal capillary refill and perfusion.
- Palpation: No enlarged lymph nodes.

ASSESSMENT AND PLAN

1. Asthma.
- Medical Reasoning: The patient has experienced an increased need to use her albuterol inhaler. She is not currently utilizing a daily medication. At this time, we will try a daily medication since it looks like she might be having some allergies.
- Patient Education and Counseling: I explained the side effects of albuterol to the patient. We also discussed Singulair and that she should start to see a difference in her breathing within approximately 1 month.
- Medical Treatment: We will start her on a daily asthma medication. She can continue to use the albuterol inhaler. We will start her on Singulair in about a month.

2. Mood.
- Medical Reasoning: The patient reports being under a lot of stress with school. I believe this may be attributing to her mood.
- Medical Treatment: I would like for the patient to be seen by a therapist. She will also complete our screening questionnaire.

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

INSTRUCTIONS

The patient will follow up in 6 weeks for recheck.