[doctor] hey jean how're you doing today
[patient] i'm doing alright aside from this foot pain that i have
[doctor] so i see here that you looks like you hurt your left foot here where you were playing soccer can you tell me a little bit more about what happened
[patient] yeah so yeah i was playing in a soccer game yesterday and i was trying to steal the ball from another player and she ended up falling directly onto my right foot and i do n't know i i mean i was trying to get around her and my body ended up twisting around her and then i accidentally felt a pain in my foot
[doctor] okay so have you ever hurt your left foot before
[patient] no i've had a lot of injuries in soccer but never injured this foot
[doctor] okay and then so after the fall and the entanglement with the other player were you able to continue playing
[patient] no i had to stop playing right away and actually being helped off the field
[doctor] wow okay and what have you been doing for the the pain since then
[patient] so i've been keeping it elevated icing it the trainer wrapped it yesterday and taking ibuprofen as well
[doctor] okay alright so without any ibuprofen can you tell me what your pain level is
[patient] without ibuprofen i would say my pain is a three
[doctor] okay and then with your ibuprofen can you tell me what your pain level is
[patient] like a seven eight
[doctor] okay so how long have you been playing soccer
[patient] really since i was like four five i've been playing a long time
[doctor] well that's cool yeah we our our youngest daughter she is almost sixteen and she plays the inner marrial soccer league they are down at the rex center did is that where you started playing or did you guys did you start playing somewhere else
[patient] yeah just like this local town leak i started playing that way and then played all throughout school
[doctor] that's
[patient] high school teams
[doctor] that's awesome so just out of curiosity with the left foot have you experienced anything like numbness or tingling or or any strange sensation
[patient] no i have not
[doctor] okay now if it's okay with you i would like to do a quick physical exam i reviewed your vitals and everything looks good blood pressure was one eighteen over seventy two heart rate was fifty eight respiratory rate was fourteen you are afebrile and you had an o2 saturation of ninety nine percent on room air on your heart exam your regular of rate and rhythm do n't appreciate any clicks rubs or murmurs no ectopic beats noted there on auscultation listening to your lungs lungs are clear and equal bilaterally so you're moving good air i'd like to do a focused foot exam on your left foot so i do see some bruising on the bottom of your foot and on the top of your foot as well now there is associated swelling and i do appreciate tenderness to palpation of your midfoot and you are positive for the piano key test on a neurovascular exam of your left foot you have a brisk capillary refill of less than three seconds dorsalis pedis pulse is intact and strong and you do have motor and sensation that it's intact to light touch now i would like to do a review of the diagnostic imaging that you had before you came in so i do notice a subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space so lem me talk to you a little bit about my assessment and plan now for for the first concern of right foot pain your right foot pain is due to a lisfranc fracture which is a fracture to one of your second metatarsal bones at the top of your foot where the metatarsals meet your cuboids now there are ligaments at the top of your foot so i'm gon na be ordering an mri to assess for injury to any of these ligaments now based on your exam and from what i'm seeing on your x-ray you're most likely going to need surgery of that foot now the surgery will place the bones back in their proper position and using plates and screws will hold them there while they heal and this is gon na allow those bones and ligaments to heal properly it is a day surgery and you will be able to go home the same day and then i'm going to have you follow up with me here in the clinic you'll be in a cast and you will need to use crutches and you will not be able to use that left foot for about six to eight weeks now after that six to eight weeks you will gradually start walking on your foot based on how you tolerate it and we'll see how you do at that point so i do believe you're gon na need surgery i i'm recommending this because there are significant complications to your foot if we do not do this poor bone and ligament healing can lead to losing the arch of your foot and you're becoming flat-footed you also have a high likelihood of developing arthritis in that foot so what i'm gon na do unfortunately you'll be out the rest of the season but we are gon na get you fixed up and ready for next season if you're okay with all of this i'm gon na have the nurse come in and get you started on your paperwork and then i will see you on monday morning and we will get your foot taken care of
[patient] alright thank you
[doctor] you're welcome

CHIEF COMPLAINT

Left foot pain.

HISTORY OF PRESENT ILLNESS

Jean Martinez is a pleasant 27-year-old female who presents to the clinic today for the evaluation of left foot pain.

The patient sustained an injury to her left foot while playing soccer yesterday. She became entangled with another player, causing the player to fall onto the patient's foot, resulting in immediate pain. After the incident, she required help to get off of the field and was unable to participate for the rest of the game. Her trainer wrapped her foot, and she has tried ice, elevation, and ibuprofen to treat her symptoms. with medication, she rates her pain as 3/10, but without medication her pain is rated as 7-8/10. There is no numbness, tingling, or other abnormal sensations associated with her pain.

Of note, the patient has sustained several injuries in the past while playing soccer, but this is her first left foot injury.

MEDICAL HISTORY

The patient reports that she has sustained several soccer injuries in the past.

SOCIAL HISTORY

The patient has been playing soccer since she was 4 or 5 years old. She is currently playing in a local league.

MEDICATIONS

The patient reports that she has been taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Reports left foot pain.
Neurological: Denies left foot numbness or tingling.

VITALS

Blood pressure: 118/72 mmHg
Heart rate: 58 bpm
Respiratory rate: 14
Temperature: Afebrile
Oxygen saturation: 99% on room air

PHYSICAL EXAM

CV: Regular rate and rhythm without clicks, rubs, or murmurs. No ectopic beats noted on auscultation of the heart. Brisk capillary refill, less than 3 seconds. Dorsalis pedis pulse is intact and strong.
RESPIRATORY: Lungs are clear and equal bilaterally.
NEURO: Motor and sensation in the left foot are intact to light touch.
MSK: Examination of the left foot: Ecchymosis on the plantar and dorsal aspects of the foot. Associated swelling. Tenderness to palpation of the midfoot. Positive piano key test.

RESULTS

X-ray images of the left foot were obtained and reviewed today. These reveal subtle dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases. There is presence of a bony fragment in the Lisfranc joint space.

ASSESSMENT

Lisfranc fracture, left foot.

PLAN

I explained the nature of her injury in detail. Based on her exam and x-ray findings, she will most likely require surgery of the left foot, but I want to order an MRI to assess for any ligamentous injuries. We discussed the procedure and postoperative expectations, such as recovery time and restrictions, at length. We also discussed the complications associated with deferring surgical intervention including poor bone and ligament healing, pes planus deformation, and a high likelihood of developing arthritis in the foot. She will be unable to participate for the remainder of the soccer season, but should be able to play next season.

INSTRUCTIONS

We will see the patient on Monday, for surgery.


[doctor] hi virginia how're you today
[patient] i'm good thanks how are you
[doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened
[patient] i was playing basketball and jerry ran into me and the inside of my knee hurts
[doctor] okay did you fall to the ground or did you just kinda plant and he pushed and you went one way and your knee did n't
[patient] i did fall to the ground
[doctor] you did fall to the ground okay and did you land on the kneecap i mean did it hurt a lot were you able to get up and continue on
[patient] i landed on my side i was not able to continue on
[doctor] okay so you get off the off the court is jerry a good player you just got ta ask that question
[patient] not really
[doctor] no
[patient] he does n't have much game
[doctor] okay okay well you know i love basketball i'm a little short for the game but i absolutely love to watch basketball so it's really cool that you're out there playing it so tell me about a little bit about where it hurts
[patient] on the inside
[doctor] on the inside of it okay and after the injury did they do anything special for you or you know did you get ice on it right away or try anything
[patient] i had ice and an ace wrap
[doctor] you had ice and what
[patient] an ace wrap
[doctor] and an ace wrap okay now how many days ago was this exactly
[patient] seven
[doctor] seven days ago okay yeah your right knee still looks a little swollen for seven days ago so i'm gon na go ahead and now i also see that you're diabetic and that you take five hundred milligrams of metformin twice a day are you still you're still on that medication is that correct
[patient] correct
[doctor] and do you check your blood sugars every morning at home
[patient] every morning
[doctor] okay great and since this i'm the reason i'm asking all these questions i'm a little concerned about the inactivity with your your knee pain and you know how diabetes you need to be very you know active and and taking your medicine to keep that under control so you know may wan na continue to follow up with your pcp for that diabetes as we go through here and just watch your blood sugars extra as we go through that now i'm gon na go ahead and examine your your right knee and when i push on the outside does that hurt at all
[patient] no
[doctor] okay and when i push on this inside where it's a little swollen does that hurt
[patient] yes
[doctor] yeah okay i'm just gon na ask a question did you hear or feel a pop in your knee when you were doing this
[patient] i did not no
[doctor] you did not okay okay what are you doing for the pain today
[patient] some exercises ice and mobic
[doctor] okay okay so i'm gon na continue all of my exam when i go ahead and pull on your knee the first thing i'm looking at is i do see some ecchymosis and swelling on the inside of that right knee and when i push around that knee i can see that there is fluid in the knee a little bit of fluid in the knee we call that effusion so i can appreciate some of that effusion and that could be either fluid or blood at this point from the injury that you had now you do have pain with palpation on the medial aspect of that right knee and that's that's concerning for me when i'm gon na just i just wan na move your knee a little bit it does n't look like when i extend it and flex it that you have a full range of motion does it hurt a lot when i moved it back a little more than normal
[patient] yes it hurts
[doctor] okay okay yeah so you do have some decreased range of motion in that right knee now i'm just gon na sit here and and lay you back and i'm gon na pull on your knee and twist your knee a little bit okay you currently there is a negative varus and valgus stress test that's really important so here's what i'm thinking for that right knee i think you have may have a medial collateral ligament strain from you know maybe the twisting motion be right before you fell to the ground i want you to continue to use an ace wrap i'm gon na give you a right knee brace we're gon na wear that for a few days and then i'm gon na send you to physical therapy so we can continue strengthening the muscles around the right knee now that x-ray as far as the x-ray results that x-ray that i did it this morning in the office the the bony alignment's in good position i do n't see any evidence of any fractures i do notice the the effusion around the right knee just a small amount of fluid but we're just gon na continue to watch that i'm gon na give you a prescription i'd like you to stop taking any of the nonsteroidals that you're taking the motrin or advil whichever one of those and i'm gon na give you meloxicam fifteen milligrams and i want you to take that daily for the pain and swelling i want you to just continue exercising with the the braces and everything on so if you can you can get out and do some light walking that'll be good and then again for your diabetes like i said just continue to watch those blood sugars daily and if you start to see any significant increase in them because of your loss of activity just reach out to your primary care physician now do you have any questions for me
[patient] when can i play basketball again
[doctor] yeah that's a great question i'm gon na ask well my first off i want to see you back here in in seven days you know in a week i want you to make an appointment we're gon na relook at it we're gon na determine if that swelling got any worse and if we need to go on to potentially ordering like a cat scan or an mri of that knee to look and see if there was any significant damage to the ligament so that's for for sure for seven days you're not gon na be playing basketball now are you in a ligue or is that just you get like pick up basketball
[patient] i just played the wife with fun
[doctor] okay okay good that's a great activity like i said i wish i could play now i i also know your your family do n't they own that sports store down right off a main street that sells a lot of sporting equipment
[patient] yeah they do
[doctor] okay i you know i'm i'm just thinking you know i need to get some new shoes for some of it my activities i love the i wish i could play basketball but i do a lot of bike riding so i'm always looking for anything that's gon na help me on the bike do you does your family have supplies like that
[patient] we do let me know and i can get you the hook up
[doctor] okay great great so i'll i i will let you know i'll just get on and take a look first but i'm gon na go ahead and get get you discharged i'll have my assistant come in we will get you discharged and like i said we will make an appointment for seven days and we will go from there any questions
[patient] i think you've answered them all thank you
[doctor] okay great

CHIEF COMPLAINT

Right knee pain.

HISTORY OF PRESENT ILLNESS

Virginia Phillips is a pleasant 53-year-old female who presents to the clinic today for the evaluation of right knee pain. The onset of her pain began 7 days ago, when she was playing basketball and another player ran into her. She states that she fell to the ground and landed on her side. She denies hearing or feeling a pop at the time of the injury. The patient localizes her pain to the medial aspect of her knee. She used ice and an ACE wrap right after the injury. Today, she notes that she has been doing exercises, ice, and Mobic for pain control.

MEDICAL HISTORY

The patient reports she is a diabetic who takes her blood sugar every morning.

SOCIAL HISTORY

Patient reports that she plays basketball at the Y for fun.

MEDICATIONS

Patient reports that she takes metformin 500 mg twice a day.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain.

PHYSICAL EXAM

MSK: Examination of the right knee: No pain to palpation of the lateral aspect of the right knee. Pain with palpation on the medial aspect of the knee. Ecchymosis and swelling on the medial aspect of the knee. Effusion is appreciated. Decreased ROM. Negative varus and valgus stress test.

RESULTS

X-rays of the right knee taken in office today reveal the bony alignment in good position. There is no evidence of any fractures. There is effusion present.

ASSESSMENT

Right knee pain, possible medial collateral ligament strain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have prescribed the patient meloxicam 15 mg once a day to treat the pain and swelling. She was advised to stop taking any anti-inflammatory such as Motrin or Advil. I have also recommended that the patient attend formal physical therapy to strengthen her right knee. I have also advised her to continue to use the ACE wrap and wear a right knee brace for a few days. She should continue light walking with her brace on. The patient was advised to stop basketball until she follows up in 7 days.

Regarding her diabetes, she should continue to monitor her blood sugars daily. She should reach out to her primary care physician if she sees an increase in her blood sugars due to loss of activity.

INSTRUCTIONS

The patient will follow up with me in 7 days to check on her progress. If her swelling has not improved, we will consider obtaining a CT or MRI of the right knee to evaluate for a possible medial collateral ligament strain.


[doctor] okay raymond it looks like you've been having some difficulty swallowing over for a period of time could you tell me like what's going on
[patient] well i've been better for the last several weeks i've been noticing that it's been hard for me to swallow certain foods and i also have pain when i swallow down in my chest
[doctor] okay and when does it does it happen every time you eat
[patient] it hurts not every time it hurts when i when i swallow most foods but it's really just the bigger pieces of food that seem like they're getting stuck
[doctor] okay and what do you mean by bigger pieces of food like what's your diet like
[patient] well things have been stressed over the last couple of months so lacks a moving from the west coast of east coast so i've been drinking more eating things like pizza burgers i know it's not good but you know it's been pretty busy
[doctor] wow that sounds kinda stressful like what are you moving for
[patient] well i'm stressed because what i'm moving because you know i i do n't like the west goes so i i decided to move but you know it's just stressful
[doctor] uh uh
[patient] because i do n't know how my dog is gon na handle the travel but i do n't wan na put them into the carbo portion of the plane we fly out of her really bad stories of dogs got in the wreck
[doctor] okay so are you thinking of driving
[patient] i i think so i think i'm i think i'm gon na end up driving but that's still a a long trip
[doctor] yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms
[patient] no i wish unfortunately i've gained some weight
[doctor] okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea
[patient] sometime my belly hurts up here
[doctor] okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool
[patient] not that i noticed
[doctor] okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt
[patient] no i did that hurts
[doctor] okay pain to palpation of epigastric area how about now
[patient] no
[doctor] okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for your i reviewed the results of your barium swallow and it showed that you have two areas of mild narrowing in the mid and lower portions of your esophagus that can be found in patients experiencing something called esophagitis so for your primary primary problem you have acute esophagitis i wan na go ahead and prescribe protonix it's forty milligrams you're gon na take that once a day you should take it the first thing in the morning i also wan na prescribe to you something called carafate you take one gram four times a day for one month that's just gon na help kind of coat your the in the lining of your esophagus and like your stomach so that you're again like not producing a whole lot of acid like your your pretty much your the acid in your stomach is getting where it does n't need to be and it's a bit too strong so we're gon na give your body time to do a reset i wan na schedule you for an upper endoscopy just to be sure we are n't missing anything else i encourage you to change your diet and decrease alcohol and caffeine i know that's gon na be pretty hard with the move but you know once especially once you're settled in it's gon na be very important for us to to like focus on like getting well and eating healthy so that you know like you can you can move about your day as best as you can and and enjoy your move i want you to consider like eating slowly and chewing your food more thoroughly so that you do n't have to deal with those big pieces i also want you to avoid citrus foods fruits and spicy foods until your symptoms have improved i wan na see you again next week for that endoscopy i know there was a lot of information do you have any questions
[patient] no i think that's all good
[doctor] okay alright thank you so much for coming in

CHIEF COMPLAINT

Difficulty swallowing.

HISTORY OF PRESENT ILLNESS

Raymond Taylor is a pleasant 67-year-old male who presents to the clinic today for difficulty swallowing. The patient notes that the pain has been occurring for the last several weeks. The pain radiates to his chest when he swallows. He notes that he does not have pain every time he eats but mostly when he has big pieces of food as they seem to get stuck. Mr. Taylor notes that it has been stressful for him the past couple of months as they moved from the West Coast to the East Coast, so he has been drinking more, and having pizza, and burgers more. He denies any weight loss, but endorses weight gain. The patient states that he has epigastric pain, but denies dark, tarry stools.

REVIEW OF SYSTEMS

Constitutional: Reports weight gain.
HENT: Reports dysphagia.
Gastrointestinal: Reports epigastric pain. Denies dark, tarry stools.
Neurological: Positive stress.

VITALS

BP: 133/70.
Heart rate looks good.
Temperature is within normal limits.
SpO2: 100%.
Respiratory rate: 19.

PHYSICAL EXAM

EYES: Equal and reactive to light.
NECK: No adenopathy, thyromegaly.
RESPIRATORY: Normal respiratory effort no respiratory distress
GI/GU: Non-distended Active bowel sounds. Pain to palpation of epigastric area. Negative McMurphy's Sign. No peritoneal signs. No rebound.
SKIN: No rash, no lesion, no bruising.
MSK: Examination of the mouth reveals no obvious ulcers or evidence of thrush present. Tonsils are midline of the neck.

RESULTS

The barium swallow study revealed two areas of mild narrowing in the mid and lower portions of your esophagus.

ASSESSMENT

Acute esophagitis.

PLAN

After reviewing the patient's examination and barium swallow findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have prescribed the patient Protonix 40 mg first thing in the morning to treat his acute esophagitis. I have also prescribed the patient Carafate 1 gram 4 times daily for 1 month to help coat the lining of his esophagus and stomach. I recommended a upper endoscopy for further evaluation. I have also advised him to change his diet, decrease alcohol, and caffeine. I have also advised him to avoid citrus foods, fruits, and spicy foods until his symptoms have improved. We discussed that he should eat slowly and chew his food thoroughly to avoid big pieces of food. All questions were answered.

INSTRUCTIONS

The patient will follow up with me in 1 week for his endoscopy.


[doctor] so gloria is a 46 -year-old female today with past medical history of diabetes and back pain and today here for shortness of breath with chf and copd also so gloria tell me what's going on
[patient] i i i'm having a lot of trouble sleeping
[doctor] okay and and how long has this been going on for
[patient] really just for about the past two weeks i i just ca n't ca n't get comfortable you know when i when i lay down in bed i just ca n't ca n't fall
[doctor] is it because you're having you ca n't sleep or you're having shortness of breath or difficulty breathing or what's going on with that
[patient] yeah i i feel like i'm just i'm just choking a few minutes after i i lay down to sleep i just ca n't catch my breath
[doctor] okay and are you and how has your pulse ox been your oxygen level been at home i know you your oxygen level here is like ninety two right now in the office which is a little bit on the low side how is how has that been at home
[patient] i can breathe fine
[doctor] just when you lay down you get short of breath okay and is it worse when you have you noticed any shortness of breath during the day when you exert yourself when you climb stairs or do other stuff
[patient] i do n't i do n't do any of that usually i just i i sit on the couch and watch my shows
[doctor] okay fair enough and how about have you noticed any weight gain or swelling in your legs or calves or anything like that
[patient] yeah i i ca n't see my ankles anymore and and yeah i i do n't know what's going on with the scale i think the numbers are off because you know suddenly i gained about ten pounds
[doctor] wow okay alright and are you taking i know you were supposed to be taking lasix and we had you on you know diet control to to prevent to limit your salt intake how is that going
[patient] i i i do n't know how much salt is in freedoes but you know i i i'm really enjoying those in last weekend we got this really big party and yeah which color is that lasix pill
[doctor] yeah it's it's the white one the round one so it sounds like you're not maybe not taking it as regularly as you should
[patient] no sir i i do n't think i am
[doctor] okay alright and are you having any chest pain or tightness in your chest or anything like that or not really
[patient] no not really
[doctor] okay
[patient] just just when i ca n't breathe good at night you know
[doctor] okay got it
[patient] yeah
[doctor] so i'll examine you in a second so it's been a couple of weeks are you coughing up anything any fevers with this at all
[patient] no no fever kinda feel like i'm just bringing a whole bunch of yuck up once in a while though especially first thing in the morning
[doctor] okay alright and how have your blood sugars been doing this time i know you're taking the metformin are you checking your accu-cheks how has that been going
[patient] i i'm sorry what's an accu-chek
[doctor] for your blood sugar check are you checking that or not really
[patient] i i i did it a couple of weeks ago
[doctor] okay
[patient] and it was about it i i think about two thirty it was okay
[doctor] okay so your hemoglobin a1c last time was seven . five and we had talked about you know trying to improve your diet we had talked about you know we wan na avoid going to insulin but it sounds like it's been a challenge to kinda control the diet and also your blood sugars have been running a little bit high
[patient] yeah
[doctor] okay alright
[patient] yeah it's it's been a challenge
[doctor] alright and any nausea vomiting or diarrhea or anything like that are you peeing a whole lot or anything like that no
[patient] yeah i'm feeling like crazy
[doctor] okay alright
[patient] ca n't figure out why because i'm not drinking very much
[doctor] alright and how is your back then has that been okay i know you're sitting you said you're sitting on the couch a lot watching tv but
[patient] yeah
[doctor] besides that anything else
[patient] yeah you know it it just it just really hurts so you know and so that's why i sit on the couch so much
[doctor] okay alright no weakness or numbness in your legs right now
[patient] no
[doctor] okay
[patient] no
[doctor] so let me examine you now gloria i'm gon na go ahead and do an exam and let's pretend i did my exam i'm just gon na verbalize some of my findings just so i can record this and put it into my my into my chart so neck exam you do have a little bit of swelling in your neck little bit of jvd no bruits your lung exam you have some crackles in both bases and some rales that i can hear and there are a little bit of intermittent wheezing as well on your heart exam you have a two over six systolic ejection murmur you've had that in the past otherwise regular rate and rhythm it does n't feel a regular your belly exam your belly's slightly distended there's no tenderness or guarding or anything like that so that does n't that looks pretty good on your leg exam you do have some one plus pitting edema or actually almost one and a half plus pitting edema in your both of your ankles no calf tenderness negative homans sign that means no blood clots otherwise neurologic exam is normal the rest of your exam is normal so what does this all mean so let me explain that so for the first problem the shortness of breath you know i think you have an exacerbation of your congestive heart failure what i'd like to do is increase your dose of lasix from twenty milligrams to sixty milligrams for the next four days i'm gon na have you check your weights everyday and also i'm gon na go ahead and have you use your albuterol and atrovent we had given you some inhalers in the past i can give you another refill if you need to help with that some of the breathing that you're having the shortness of breath so i'd like to get some of this fluid off you have you check your weights daily we'll have you increase your dose of lasix we'll have you use a breathing treatments and see if that helps your shortness of breath i'd like to have you come back in about couple days actually i wan na see how you're doing and if it does n't get better we may have to increase the dose or send you to the hospital okay
[patient] i do n't want to go to the hospital doctor
[doctor] yeah so let's try to let's try to use the lasix and let's try to let's try to you know use the breathing treatments and and do that for the second problem the diabetes that we just talked about i like to go ahead and order another blood test another hemoglobin a1c i think we need to your blood sugars have been running a little bit high in the past and we've had a hard time but it's been a while since we checked your last one so i wan na check another one today to see where we are and when we have you come back in a couple days we should have the results back we can then adjust your metformin or we may have to adjust some of the you know add a different medication at that point but but right now i'm gon na order some blood tests we'll have you come back in a couple of days and then we can reassess at that point okay
[patient] so i had a piece of cake before i came in here is that gon na affect the the lab work
[doctor] yeah we'll probably do a fasting blood sugar we'll we'll order the hemoglobin a1c that should n't be actually matter because that checks long term but if we need your blood sugar may be elevated today i i would n't be surprised alright and i forgot to examine your back by the way so on your back exam you do have some tenderness in the paraspinal areas of your back in the in the lower back mostly no midline tenderness you have good reflexes so i think this is all muscular pain right now for your back pain i'm gon na go ahead and put you on some naprosyn and some flexeril which is a muscle relaxer i'm gon na give you some exercises you can do to help you get off the couch it'll also help your blood sugar and why do n't we have you if that does n't work the the pain medicine and the physical we can start physical therapy and see if that helps okay
[patient] okay
[doctor] any questions about that
[patient] i do n't think so which color pills
[doctor] i think it's a white pill and it's round
[patient] okay
[doctor] about this big
[patient] alright sounds good
[doctor] anything else gloria
[patient] no that's it
[doctor] alright thanks for coming in today

CHIEF COMPLAINT

Dyspnea.

MEDICAL HISTORY

Patient reports history of diabetes, back pain, congestive heart failure, and chronic obstructive pulmonary disease.

SOCIAL HISTORY

Patient reports living a sedentary lifestyle.

MEDICATIONS

Patient reports she is not consistent with taking Lasix and metformin.

REVIEW OF SYSTEMS

Constitutional: Reports 10 pound weight gain. Denies fever.
Cardiovascular: Denies chest pain or tightness.
Respiratory: Reports orthopnea and productive cough. Denies dyspnea on exertion.
Gastrointestinal: Denies nausea, vomiting, or diarrhea.
Genitourinary: Reports polyuria.
Musculoskeletal: Reports back pain and lower extremity edema.
Neurological: Denies lower extremity weakness or numbness.

VITALS

Oxygen saturation: 92%

PHYSICAL EXAM

Neck
- General Examination: Slight swelling. Mild JVD. No bruits.

Respiratory
- Auscultation of Lungs: Mild rales heard at the base bilaterally and slight intermittent wheezing.

Cardiovascular
- Auscultation of Heart: 2 out of 6 systolic ejection murmur, otherwise regular rate and rhythm.

Gastrointestinal
- Examination of Abdomen: Slightly distended. No tenderness or guarding.

Musculoskeletal
- Examination: 1.5+ pitting edema in the ankles bilaterally. No calf tenderness. Negative Homan's sign. Slight tenderness in the paraspinal area, mostly in the lower back. No midline tenderness. Good reflexes.

RESULTS

Hemoglobin A1c: 7.5

ASSESSMENT AND PLAN

1. Shortness of breath.
- Medical Reasoning: I believe this is an exacerbation of her congestive heart failure.
- Patient Education and Counseling: I advised the patient to monitor her weight daily.
- Medical Treatment: She will increase her dose of Lasix from 20 mg to 60 mg for the next 4 days. She should also use her albuterol and Atrovent inhalers as needed. If her symptoms don't improve in the next couple of days, we will either increase her doses or have her go to the hospital.

2. Diabetes type 2.
- Medical Reasoning: Her recent blood glucose levels have been elevated.
- Patient Education and Counseling: We discussed the possibility of needing to add another medication to her regimen.
- Medical Treatment: We are going to order a repeat hemoglobin A1c and adjust her dose of metformin accordingly.

3. Back pain.
- Medical Reasoning: This appears to be all muscular pain.
- Patient Education and Counseling: We discussed exercises she can do to help her pain and that ff this doesn't help we can consider physical therapy.
- Medical Treatment: Prescriptions provided for Naprosyn and Flexeril.

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

INSTRUCTIONS

We will have her follow up in a couple of days.


[doctor] hey matthew how're you doing
[patient] hey doc i'm doing pretty good how are you
[doctor] i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that
[patient] yeah i did my wife and i were on a walk yesterday and i was just talking to her and and stepped off the curb and landed on it wrong it's kind of embarrassing but yeah it's been killing me for a couple days now
[doctor] okay now when you fell did you feel or hear a pop or anything like that
[patient] i would n't say i really heard a pop it was just kind of really kind of felt extended and stretched and it it's just been really bothering me ever since kind of on the outside of it
[doctor] okay and then were you able to walk on it after the incident
[patient] i was able to get back to the house because i did n't wan na you know make my wife carry me but it was it was painful
[doctor] okay and then have you done any or had any injuries to that ankle before
[patient] nothing substantial that i would say in the past
[doctor] okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less
[patient] i have taken some ibuprofen and then i just tried to elevate it and ice it a little bit and keep my weight off of it
[doctor] okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me
[patient] i would say it's about an eight
[doctor] okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then
[patient] maybe a seven it it's a little
[doctor] okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there
[patient] we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time
[doctor] yeah i
[patient] no i have n't been there yet
[doctor] yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay
[patient] awesome
[doctor] so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up
[patient] no i think that sounds like a plan
[doctor] okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks
[patient] awesome thanks document
[doctor] alright thanks bye-bye

CHIEF COMPLAINT

Left ankle pain.

HISTORY OF PRESENT ILLNESS

Matthew Murphy is a pleasant 20-year-old male who presents to the clinic today for the evaluation of left ankle pain. The onset of his pain began 2 days ago, when he stepped off of a curb and landed on his left ankle wrong. He denies hearing a pop at the time of the injury, however, he describes his ankle as feeling extended and stretched. He was able to ambulate back to his house after the incident but with pain. He denies any previous injuries to his left ankle. His pain is localized to the lateral aspect of his left ankle and can be rated at 8 out of 10 without medication. When taking ibuprofen his pain level is 7 out of 10. He states he has also iced and elevated his ankle.

SOCIAL HISTORY

Patient reports that he has been working from home since the start of COVID-19 and enjoys taking lots of walks.

MEDICATIONS

Patient reports taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Patient reports left ankle pain.

VITALS

Vitals are slightly elevated due to pain level but are otherwise stable.

PHYSICAL EXAM

NEURO: Normal strength and sensation bilaterally.
MSK: Examination of the left ankle: Ecchymosis noted over the lateral malleolus. Edema is present. Tenderness to palpation laterally. No joint laxity appreciated. No bony tenderness to palpation of the foot. Capillary refill is brisk at less than 3 seconds bilaterally. Strong dorsalis pedis pulses bilaterally.

RESULTS

These reveal no fracture or bony abnormalities.

ASSESSMENT

Left ankle sprain of the lateral ligament complex.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. We discussed that his symptoms are consistent with an ankle sprain of the lateral ligament complex. The nature of the diagnosis and treatment options were discussed. At this time he will continue to follow the RICE protocol. He will continue to take NSAIDs as needed for pain and swelling. He will also be placed into an Aircast for ankle stabilization and will be provided crutches in order to remain non-weight-bearing. We discussed that it may be a few days before he feels able to tolerate walking. I also advised him that his symptoms will likely start to improve significantly over the next 4 to 6 days.

INSTRUCTIONS

The patient will follow up with me in 2 weeks to assess his progress, sooner if needed.


[doctor] hey anna good to see you today so i'm looking here in my notes says you have you're coming in today for some right ankle pain after a fall so can you tell me what happened how did you fall
[patient] yeah so i was taking out the trash last night and i ended up slipping on a patch of ice like and then when i fell i heard this pop and it just hurts
[doctor] okay so have you been able to walk on it at all or is it you know
[patient] at first no like my friend who was visiting thankfully had to help me get into the house and i you know and now i'm able to put like a little bit of weight on it but i'm i i'm still limping
[doctor] okay well you know that's not good we'll we'll hopefully we can get you fixed up here so how much how much pain have you been in on a scale of one to ten with ten being the worst pain you ever felt
[patient] it's it's more like so when i first fell it was pretty bad but now it's it's at like a six you know like it's uncomfortable
[doctor] okay and how would you describe that pain is it a constant pain or is it only when you move the ankle
[patient] it's it's constant it's like a throbbing pain you know and like when i touch it it feels kinda warm
[doctor] okay alright yeah but yeah i can feel it here so it does feel a little bit warm so i said you've been in a little bit of pain so have you taken anything for it
[patient] well like last night i iced it and i kept it elevated you know i also took some ibuprofen last night and this morning
[doctor] alright has the ibuprofen helped at all
[patient] not really
[doctor] okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before
[patient] so you know in high school i used to play a lot of soccer but and and like i had other injuries but i've never injured like this particular ankle before but because i used to play like all the time i knew what i was supposed to do but this is i also knew that it was it was time to come in
[doctor] okay yeah yeah definitely if you if you ca n't walk on it we definitely good thing that you came in today and we were able to see you so have you experienced any numbness in your foot at all
[patient] no no numbness and i do n't think i've had like any tingling or anything like that
[doctor] okay that that's good yeah it sounds like you have sensation there so yeah that that's really good so let me do a quick physical exam on you so i reviewed your vitals your blood pressure was one twenty over eighty which is good your heart rate your spo2 was ninety eight percent which is good that means you're you're getting all of your oxygen and so let me go ahead and look at your ankle real quick so when i press here does that hurt
[patient] yeah
[doctor] alright what about here
[patient] yeah
[doctor] okay so looking at your ankle and your right ankle exam on the skin there is ecchymosis so you have that bruising which you can see of the lateral
[patient] malleolus
[doctor] malleolus associated with swelling there is tenderness to palpation of the anterior laterally in the soft tissue there is no laxity on the anterior drawer and inversion stress there is no bony tenderness on palpation of the foot on your neurovascular exam of your right foot there your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch alright so we did get an x-ray of your ankle before you came in and luckily it's there is no fractures no bony abnormalities which is really good so let me talk a little bit about my assessment and plan for you so for your right ankle pain your symptoms your symptoms are consistent with a right ankle sprain have you sprained your ankle before most times people do the athletics play soccer it happens every so often but have you done that before
[patient] no i do n't think so
[doctor] okay well you're one of the lucky ones some of my my patients that play sports they sprain their ankle seems like every other week so good for you so for that that that ankle sprain i just want to keep i want you to keep your leg elevated when you're seated and i want you to continue to ice it you can ice it let's say five times a day for twenty minutes at a time just to help that swelling go down i'm gon na give you an air cast to help you stabilize the ankle so keep it from moving and then i'll give you crutches and so i want you to stay off that leg for about one to two days and then you can start walking on it as tolerated tolerated so how does that sound
[patient] it's alright
[doctor] alright so do you have any questions for me
[patient] yeah like how long do you think it's gon na take for me to heal
[doctor] i mean it should take a a couple of days i mean i think in a day or two you will be able to walk on it but still think it will be sore for the next couple of weeks you know your ankle sprain seems to be not the worst but it's kinda you know medium grade ankle sprain so as i would say about two to three weeks you should be back to normal you will see some of that bruising go away
[patient] yeah okay can i get a doctor's note
[doctor] no because you need to go back to work because you work on the computer not running so
[patient] fine
[doctor] yeah you ca n't get a doctor's note so if you if i write a note i'm gon na tell your boss that you have to go to work
[patient] okay thanks
[doctor] so i i would n't do that but yeah but otherwise if if if you continue to have pain after this week if you feel like it's not getting better please feel free to contact the office and we can get you back in and possibly do an mri if we you know need to
[patient] okay
[doctor] alright
[patient] alright
[doctor] anything else
[patient] no that's it
[doctor] alright thanks

CHIEF COMPLAINT

Right ankle pain.

HISTORY OF PRESENT ILLNESS

Anna Diaz is a pleasant 31-year-old female who presents to the clinic today for the evaluation of right ankle pain. The onset of her pain began when she slipped on a patch of ice while taking out the trash. She states that she heard a pop at the time of the injury. The patient reports that she was unable to ambulate on her right ankle initially after the injury; however, she is now able to bear some weight on her right ankle, but she is still limping. The patient rates her pain level as a 6 out of 10. Ms. Diaz describes her pain as constant and throbbing. She reports that her right ankle is warm to the touch. She denies any numbness or tingling in her right foot. The patient has been icing and elevating her right ankle while also utilizing ibuprofen last night and this morning, which did not provide her with any relief. The patient states that she used to play a lot of soccer in high school so she notes that she has had other right foot injuries but not like this.

REVIEW OF SYSTEMS

Musculoskeletal: Positive right ankle pain.
Skin: Positive warmth to the right foot.
Neurological: Denies any numbness or tingling.

VITALS

BP: 120/80
SPO2: 98%.

PHYSICAL EXAM

CV: Capillary refill is less than 3 seconds. Strong dorsalis pedis pulse.
NEURO: Normal sensation. Sensation is intact to light touch distally.
MSK: Examination of the right ankle reveals ecchymosis over the lateral malleolus associated with swelling. Tenderness to palpation anterolaterally in the soft tissue. No laxity on anterior drawer or inversion stress. No bony tenderness on palpation of the foot.

RESULTS

X-ray of the right ankle taken in office today reveals no fracture or bony abnormalities.

ASSESSMENT

Right ankle sprain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her symptoms are consistent with a right ankle sprain. I have recommended that we treat the patient conservatively. I have advised her to keep her right leg elevated when she is seated. I have also advised her to ice her right ankle 5 times per day for 20 minutes at a time to help with the swelling. I have also recommended that the patient be placed in an Aircast to stabilize the ankle. She will remain non-weight-bearing for 1 to 2 days, we provided her with crutches today, and then she can begin weight-bearing as tolerated.

INSTRUCTIONS

If her pain does not improve over the next week, she will contact the office and we will obtain an MRI.


[doctor] hey gabriel i'm doctor scott good to see you today i know you've heard about dax is it okay if i tell dax a little bit about you
[patient] sure
[doctor] okay so gabriel is a 43 -year-old male today here for back pain evaluation and also has a past medical history of diabetes high blood pressure and high cholesterol so gabriel tell me what's going on with your back
[patient] well i was working in the yard and you know bent over to pick something up and i got this pain and you know across the lower part of my back and then it went down my left leg and you know it's been going on for about four days and just does n't seem to be getting any better
[doctor] okay are you a big gardener or this is something that you just started working in the yard
[patient] yeah i know my wife held a gun to my head make me go out there work in the yard and carry some stuff around it's not my not my first choice but
[doctor] sure sure
[patient] but that day i i lost the i lost the argument
[doctor] yeah yeah that happens to all of this so when this back pain happened so it was basically you were lifting you were bending down to lift something up and you had the sharp pain going down your right leg you said
[patient] left leg
[doctor] left leg okay got it sorry and any weakness or numbness in your legs or just the pain mostly
[patient] in in certain positions i get some tingling but no mostly just pain
[doctor] okay and any loss of bowel or bladder function at all or anything like that
[patient] no
[doctor] okay and have you had any back surgeries or back problems in the past or this is kind of the first time
[patient] no surgeries you know i've i've had back pain occasionally over the years
[doctor] okay have you had any any have you tried anything for pain for this have you tried any any medications at all
[patient] i've had ibuprofen it it helped some
[doctor] okay got it alright well i'll i'll examine you in a second but before we do that let's talk about some of the other conditions that we're kinda following you for i'm looking at your problem list now and you've got a history of diabetes and you're on metformin five hundred milligram twice a day and your how are you doing with your blood sugars and your and your diet and exercise
[patient] yeah i i check my sugar two or three times a week most of the time it's in that one twenty to one forty range
[doctor] okay
[patient] yeah i take my medicine okay my diet is alright you know i could be fifteen pounds lighter that would be alright but
[doctor] sure
[patient] i i i think the sugar has been okay
[doctor] okay we checked your hemoglobin a1c last time i'm looking at your records in epic and it showed that it was you know seven . one so it's it's it's good but it could be better any you know we talked about it controlling your diet or improving your diet and trying to have a balanced meal and not eating some of these sweets and high sugar items how is that going i know you had talked about your wife being a great cook and making cookies and that's hard to stay away from obviously how are things going with that
[patient] yeah she still makes cookies and i still eat them but you know we are trying to trying to do better trying to stay away from more of those carbs and focus on you know less carby less sweet stuff
[doctor] okay alright yeah that's always a struggle i certainly understand but you know really important with your diabetes just to prevent some of the complications like kidney failure and eye problems and just keep your sugar under balance so i'll order another hemoglobin a1c today we'll check that again today and and you know just reemphasizing the controlling your diet and exercise is super important and then we'll have those results back we'll we'll see if we need to make any modifications okay
[patient] okay
[doctor] for your high blood pressure your blood pressure in the clinic looks pretty good it's about one twenty over seventy right now we have you on norvasc five milligrams once a day how are things going with that are you are you checking that periodically or any issues with that at all
[patient] yeah i guess i check it maybe once a week or two or three times a month and it it the vast majority of the time when i check it it's good usually either that one twenty to one thirty over seventy to eighty range i i think the blood pressure's okay
[doctor] okay
[patient] i have n't had any real problems there i i have had some some swelling in my ankles though
[doctor] okay is that new or is that been going on for a while
[patient] well it it started maybe i do n't know a month or two after i started the norvasc
[doctor] okay
[patient] and i was just wondering if the two might be related
[doctor] yeah i mean certainly it could be it is you know sometimes that medication can cause that so i'll i'll examine you in a second and see if we need to make any modifications okay
[patient] okay
[doctor] alright so and your anything else bothering you today
[patient] no i'm we're doing okay i think
[doctor] so let me examine you for a second i'm gon na go ahead and gabriel i'm gon na do my magic exam now let's pretend i i'm just gon na verbalize some of my findings as i do my exam and so
[patient] these are like my video visit exams
[doctor] exactly so your neck exam has no jvd there is no bruits that i can hear your lung exam no rales no wheezing on your heart exam you do have a two over six systolic ejection murmur you had that in the past so i'm not too worried about that otherwise regular rate and rhythm on your heart exam on your on your on your belly exam is nice and soft on your back exam you do have some tenderness on the left paraspinal area right where i'm pressing right there your straight leg raise test is negative your reflexes are normal you have some just some tenderness in the lower back in the paraspinal area of your back when i palpate there otherwise your neurological exam is normal on your extremity exam you do have this one plus nonpitting edema of your lower extremities which is a little bit of swelling in your ankles no calf tenderness negative homans sign no signs of blood clot that's what that means so let me just review what you know explain what all this means so the back pain the first problem that you're here today for i think this is more of a muscular sprain i'm gon na recommend we start you on some anti-inflammatory naprosyn five hundred five hundred milligrams twice a day and flexeril ten milligrams twice a day as well i'm gon na refer you to for for physical therapy to help strengthen some of the muscles in your lower back i do n't think you need an x-ray at this stage why do n't we start with physical therapy and the muscle relaxers and the pain medicines if it does n't get better then we can get an x-ray but right now i would start with that if that's okay with you any questions about that
[patient] no
[doctor] okay for the diabetes the the second problem that we talked about today i'm gon na order another hemoglobin a1c continue the metformin five hundred milligrams twice a day why do n't we have you come back in about two weeks and we should have some of the results back and we can discuss if we need to make any modifications for that but right now we will continue the course and we will go from there okay for the high blood pressure you do have this one plus edema in your legs i'm gon na go ahead and order some blood work today i'm gon na go ahead and stop the norvasc and we'll put you on some hydrochlorothiazide ten milligrams once a day and if that does n't get if the swelling does n't go away i'm gon na do some more testing for right now let's get some sort off with some cbc and a bmp i'm gon na check your kidney function i'm gon na get another ekg and also i'm gon na get a chest x-ray and we'll go from there but hopefully this will go away once we stop this medication since it started around that time okay okay and i think that's it anything else we forgot about do you need refills for anything
[patient] no i i think i'm okay you gave me a year's worth of refills last time we were together
[doctor] okay sounds great alright thanks gabriel good seeing you again
[patient] good to see you thanks

CHIEF COMPLAINT

Back pain evaluation.

MEDICAL HISTORY

The patient has a history of diabetes, hypertension, and high cholesterol.

SURGICAL HISTORY

He denies previous back surgeries.

MEDICATIONS

The patient currently utilizes metformin 500 mg twice daily and Norvasc.

REVIEW OF SYSTEMS

Cardiovascular: Reports ankle swelling.
Musculoskeletal: Reports lower back pain.
Neurological: Reports tingling in left leg. Denies weakness or numbness in legs, or loss of bowl or bladder function.

PHYSICAL EXAM

Neurological
- Orientation: Alert and oriented x3. Cranial nerves grossly intact. Normal gait.

Neck
- General Examination: No JVD. No bruits.

Respiratory
- Auscultation of Lungs: No wheezes, rales.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. 2/6 systolic ejection murmur. Otherwise, regular rate and rhythm.

Musculoskeletal
- Examination: Tenderness on the left paraspinal area. Straight leg raise test is negative. Reflexes are normal. 1+ nonpitting edema of lower extremities. No calf tenderness. Negative Homan's sign.

ASSESSMENT AND PLAN

1. Lower back pain.
- Medical Reasoning: I believe this is more of a muscular sprain.
- Patient Education and Counseling: We discussed treatment options today.
- Medical Treatment: I am going to start him on Naprosyn 500 mg twice a day and Flexeril 10 mg twice a day. I will refer him for physical therapy to help strengthen some of the muscles in his lower back.
- Additional Testing: I do not think he needs an x-ray at this stage, however if he does not improve, we will order one for further evaluation.

2. Diabetes.
- Medical Reasoning: His most recent A1c was 7.1 and his blood sugar levels are typically between 120-140.
- Patient Education and Counseling: We discussed treatment options today.
- Medical Treatment: He will continue the metformin 500 mg twice a day.
- Additional Testing: I am going to order another hemoglobin A1c.

3. Hypertension.
- Medical Reasoning: He does have 1+ edema in his legs.
- Patient Education and Counseling: We discussed treatment options today. I explained that his edema is likely caused by the Norvasc.
- Medical Treatment: The patient will discontinue the use of Norvasc and we will start him on hydrochlorothiazide 10 mg once a day.
- Additional Testing: I will order a CBC and BMP. Additionally, I will order a repeat EKG, as well as a chest x-ray.

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

INSTRUCTIONS

The patient will follow up in 2 weeks.


[doctor] hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee
[patient] yes i hurt my knee when i was skiing two weeks ago
[doctor] okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury
[patient] so i was flying down this black diamond you know like i like to do
[doctor] yes
[patient] and this kid who was going faster than me spent by me so then i tried to speed past them and then i ran into a tree and twisted my knee
[doctor] so we were downhill skiing racing at this point okay is it your left or your right knee
[patient] it's my right
[doctor] okay and does it hurt on the inside or the outside
[patient] the inside
[doctor] okay so the medial aspect of the right knee when you fell did you hear a pop
[patient] i did yes
[doctor] okay alright
[patient] i think that was my left knee
[doctor] okay okay alright so we got we got ta pick one if it if it
[patient] i'm just trying to be real
[doctor] no
[patient] what happens in the in a real
[doctor] a hundred percent so how about this right now you're like i what i'm hearing is that you're experiencing bilateral knee pain like both of your knees hurt but i'm assuming that like your right knee hurts more is that correct
[patient] yeah my left knee does n't really hurt
[doctor] uh uh
[patient] that's the one that popped it the left knee just feels unstable but my right knee hurts
[doctor] gotcha gotcha okay yeah i think hmmm alright so we're gon na we're gon na go ahead and look at this sort of but on a scale of one to ten how severe is your pain
[patient] it's a seven
[doctor] okay that's pretty bad alright and does it has it been increasing or like rapidly or slowly over the last few days
[patient] it's been slow
[doctor] okay alright
[patient] but sometimes it gets to an eleven
[doctor] okay what would do you know if you are doing something that would cause it to be an eleven are you back on your ski's
[patient] no i ca n't ski
[doctor] okay
[patient] usually when i walk my dog
[doctor] okay does it hurt more when you walk for longer periods of time
[patient] yes
[doctor] okay how long does the pain last
[patient] for as long as my walk is and i do n't sometimes i walk five minutes kinda depends on the wind
[doctor] okay alright
[patient] sometimes i walk there is
[doctor] okay alright have you done anything to help with the pain
[patient] well i wear a brace and i have used a lot of thc cream on it
[doctor] okay alright thc cream is an interesting choice but do you think that's been helpful
[patient] yes
[doctor] alright have you taken
[patient] reasons
[doctor] not a problem have you taken any medications
[patient] no just gummies
[doctor] okay like vitamins or more thc
[patient] kind of like thc gummies
[doctor] thc gummies
[patient] my grandma gave them to me
[doctor] thc gummies from grandma that's an excellent grandmother that you have okay have you noticed any swelling stiffness tenderness
[patient] yeah i i get a lot of swelling and it really is it's very stiff in the morning until i get walking
[doctor] okay alright and then have you had any hospitalizations or surgeries in the past
[patient] well i had surgery on my right knee before
[doctor] okay so you've had surgery before alright do you remember what kind of surgery
[patient] i do n't know they told me they reconstructed the whole thing i was fourteen i was a really good gymnast back then really good
[doctor] okay
[patient] and i was doing a back summer salt and i felt a pop then and then since that time i've really had problems with my knee
[doctor] uh uh
[patient] but you know the athlete that i am i can still really ski very well so i just kept going
[doctor] okay
[patient] and i'm really tough my pain tolerance is very high
[doctor] okay okay okay how so do you have any other exercises that i might wan na know about outside of intense gym and ski events
[patient] no i think that's about it
[doctor] okay and how frequently do you normally ski
[patient] i ski probably three times a week
[doctor] okay and then are you on any medications at this time other than the thc
[patient] no
[doctor] okay alright what
[patient] nothing no
[doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and start my examination i'm just gon na call it out for the sake of being able to document it appropriately and you or just just let me know if you want me to explain anything further so with your knee i know that you said it hurts on the right inside a lot right so when i press on the inside of your knee does that hurt
[patient] yes
[doctor] okay and when i press on the outside of your left of your right knee sorry does that hurt
[patient] no
[doctor] okay alright so when i move your your kneecap does that hurt
[patient] no it kinda makes a shooting pain down to my ankle though
[doctor] okay
[patient] but it does n't hurt my knee
[doctor] okay so does the pain radiate frequently
[patient] no
[doctor] okay
[patient] i've never really noticed it just messed with my kneecap
[doctor] okay alright on your skin exam i do appreciate some mild swelling and bruising that's really interesting since it's been two weeks with your knee are you able to bend it
[patient] yes
[doctor] okay and then when you walked in on your gait i think i think i did appreciate a slight limp are you i i i i think you are you are protecting one of your knees does that sound familiar
[patient] yeah i waddle pretty pretty good now
[doctor] okay alright and when you move your knee away from your body you're bending like your you're pulling it towards me does that hurt
[patient] yes
[doctor] okay and then when you pull your knee back towards you does that hurt
[patient] no
[doctor] alright so pain on dorsiflexion but not on plantar flexion plantar flexion okay alright so what we are gon na do right now i think i'm gon na look at your x-rays but when i when i look at the results of your x-ray i do not appreciate any fracture what i am noticing is the development of a little bit of arthritis and that could explain like why you say that your joints hurt a bit more during like windy weather and what not so this is what we're gon na do for my assessment and plan right the first thing is i think you have a strain of your posterior cruciate ligament what that means is what that will mean for you though is that we are gon na continue to brace your right knee that's gon na hopefully take off some of the stress that you might be putting on it especially since you're limping i am going to recommend you for physical therapy i think it would be an i think it's a good idea to maybe start three times a week to get your strength back into your knee i would recommend not skiing or doing any gymnastics for now and i think that physical therapy will really help considering the injury that you had when you were fourteen i'm gon na prescribe you some medications i do n't necessarily recommend consuming gummies at the same time but the medications i'm gon na give you are gon na be meloxicam fifteen milligrams you're gon na take that once a day that will help with like the swelling and the bruising i'm also gon na prescribe you just like a higher strength nsaid so ibuprofen eight hundred milligrams a day you can take that twice a day as needed for your left knee i think you are i think you just kind of like strength a little bit but like not enough to necessarily require any kind of like medication or bracing i think you just take it easy on your body i know that you're like very active from what i hear and i i think that that's really exciting but i think you might need to listen to your body and give yourself a bit of a break you'll be able to do like several workouts when you go to when you go to physical therapy but you know let the yeah let your therapist be your guide about like what you should and should not be putting your body through does that make sense
[patient] yes
[doctor] alright do you have any questions right now
[patient] no thank you so much
[doctor] no problem

CHIEF COMPLAINT

Right knee injury.

HISTORY OF PRESENT ILLNESS

Elizabeth Ross is a pleasant 91-year-old female who presents to the clinic today for the evaluation of a right knee injury. The onset of her pain began 2 weeks ago, when she was downhill skiing. She states she ran into a tree and twisted her right knee. At the time of the injury, she also heard a pop in her left knee, however she denies left knee pain. The patient locates her pain to the medial aspect of her right knee. Currently, her pain level is 7 out of 10, however she notes this can reach an 11 out of 10 at times with prolonged ambulation. The patient states that her pain has been slowly increasing over the last few days. She experiences limping with ambulation. The patient states that her pain lasts for as long as she is ambulating. She denies radiating pain. She also reports constant swelling and stiffness in the morning. Her stiffness will resolve with ambulation. The patient has been wearing a brace and using THC cream, which has been helpful. She denies taking any medications for pain, however she has been utilizing THC gummies, which have been beneficial.

The patient has a history of a right knee reconstruction when she was 14 years old. She states that she was a good gymnast at that time. The patient adds that she has had problems with her right knee since that time. She denies any other exercises outside of intense gym and ski events. The patient states that she normally skis 3 times per week.

SURGICAL HISTORY

The patient reports a history of total right knee reconstruction at the age of 14.

MEDICATIONS

She denies needing medications.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain, swelling, and stiffness. Denies left knee pain.

PHYSICAL EXAM

MSK: Examination of the right knee: Mild effusion. The patient ambulated with an antalgic gait. Pain with dorsiflexion, but not with plantarflexion.

RESULTS

4 views of the right knee were taken. These reveal no evidence of any fractures. There is development of mild arthritis.

ASSESSMENT

1. Right knee posterior cruciate ligament strain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have explained to her that her x-rays did not reveal any signs of a fracture. I have recommended that we treat the patient conservatively with continued bracing. We will initiate formal physical therapy 3 times per week to strengthen her right knee. Additionally, I have prescribed the patient meloxicam 15 mg and ibuprofen 800 mg twice daily as needed. She should discontinue the use of her THC gummies while taking these medications.

Regarding her left knee, I do not believe she will need any further medications to treat this. I have advised her to avoid skiing or gymnastics at this time.


[doctor] hi , brian . how are you ?
[patient] hi , good to see you .
[doctor] it's good to see you too . so , i know the nurse told you a little bit about dax .
[patient] mm-hmm .
[doctor] i'd like to tell dax about you , okay ?
[patient] sure .
[doctor] so , brian is a 58 year old male with a past medical history significant for congestive heart failure and hypertension , who presents today for follow-up of his chronic problems . so , brian , it's been a little while i've seen you .
[patient] mm-hmm .
[doctor] whats , what's going on ?
[patient] i , i just feel out of sorts lately . i do n't know if it's the change in the seasons or if we're just doing a lot of projects around the house and , and some , some construction on our own . i'm just feeling out of it . lack of , uh , energy . i'm just so tired and fatigued , and i feel kinda ... i feel lightheaded every once in a while .
[doctor] okay . all right . um , how long has that been going on for ?
[patient] uh , probably since labor day , so about five weeks or so .
[doctor] okay . and , have you noticed any , like , symptoms of weight gain , like , like swollen legs , or , you know , your belly feels bloated and things like that ?
[patient] i feel , i feel bloated every once in a while .
[doctor] okay . all right . um , and , are you taking your , your medications ?
[patient] uh , yes , i am .
[doctor] okay . and , how about your diet ? are you watching your diet ?
[patient] uh , it's been a little bit of a struggle . we began construction on our kitchen over labor day weekend , and it was ... hard to cook or prepare meals so we ate out a lot, and not always the best food out. it , it , it kind of reeked havoc , uh , so it's been maybe off a little bit .
[doctor] okay . all right . and , how about , you know , other symptoms , like , have you had a fever or chills ?
[patient] no .
[doctor] okay , and any problems breathing ? do you feel short of breath ?
[patient] uh , just when i'm doing doing the projects . again , not even lifting anything really heavy , it's just that if i'm ex- exerting any energy , i , i kinda feel it at that point .
[doctor] okay . do you have any chest pain ?
[patient] slight cramps . that seems to go away after about , maybe about an hour or so after i first feel it .
[doctor] okay , and how about a cough ?
[patient] a , a slight cough , and again , i'm not sure if it's just the change of seasons and i'm getting a cold .
[doctor] mm-hmm . okay . all right . well , you know , for the most part , how , you know , before all of this-
[patient] mm-hmm .
[doctor] . how were you doing with your heart failure ? i know that we've kinda talked about you being able to watch your healthy food intake and that's been kind of a struggle in the past .
[patient] i , i , i've actually been pretty good about that ever since . the , the , the last year , it's been a little chaotic , but i wanted to make sure i stayed on top of that .
[doctor] okay . all right . are you excited for halloween ?
[patient] uh , ca n't wait .
[doctor] okay .
[patient] our home renovations should be complete by then
[doctor] all right , yeah , right .
[patient] yeah .
[doctor] and , so , lastly , for your high blood pressure , how are you doing with that ? have , are , did you buy the blood pressure cuff like i asked ?
[patient] yeah , i , i did , and we do mon- , i , i monitor it regularly . my wife makes sure i stay on top of that , but it's been pretty good .
[doctor] okay . all right . well , i know you did the review of systems sheet when you checked in , and you were endorsing this fatigue-
[patient] mm-hmm .
[doctor] . and a little dizziness and we just talked a lot about a lot of other symptoms .
[patient] mm-hmm .
[doctor] any other symptoms i might be missing ? nausea or vomiting , diarrhea ?
[patient] no .
[doctor] anything like that ?
[patient] no .
[doctor] okay . all right . well , i just want to go ahead and do a quick physical exam .
[patient] mm-hmm .
[doctor] hey , Sarah ? show me the vital signs . so , looking at your vital signs here in the office , everything looks good . you know , your blood pressure and your heart rate and your oxygenation all look really good .
[patient] mm-hmm .
[doctor] so , i'm gon na just take a listen to a few things and check some things out , and i'll let you know what i find , okay ?
[patient] perfect .
[doctor] okay . so , on your physical examination , you know , i do appreciate some jugular venous distention to-
[patient] mm-hmm .
[doctor] to about eight centimeters . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which we've heard in the past . and , on your lung exam , i do appreciate some fine crackles at the bases bilaterally , and your lower extremities have , you know , 1+ pitting edema . so , what does all that mean ? that means i think you're retaining a little bit of fluid .
[patient] mm-hmm .
[doctor] okay ? i wan na just go ahead and look at some of your results , okay ?
[patient] sure .
[doctor] hey , Sarah ? show me the chest x-ray . so , looking here at the results of your chest x-ray , it does look like you have a little bit of fluid in your lungs there , and that can be just from , um , your heart failure , okay ? hey , Sarah ? show me the echocardiogram . so , this is the echocardiogram that we did about four months ago , and this shows that the pumping function of your heart is a little bit reduced at 45 % , and it also shows that leaky valve , the mitral regurgitation that , that you have , okay ? um , so , let me just go over and talk about , a little bit , my assessment and my plan for you .
[patient] mm-hmm .
[doctor] okay ? so , for your first problem , your congestive heart failure , i think you're retaining fluid , and i wan na go ahead and increase your lasix to 80 mg once a day .
[patient] mm-hmm .
[doctor] i want you to weigh yourself every day . i want you to call me if you're gaining more weight .
[patient] mm-hmm .
[doctor] and , i certainly want you to call me if you have any other symptoms of shortness of breath , and i wan na go ahead and order another echocardiogram , okay ?
[patient] sure .
[doctor] hey , Sarah ? order an echocardiogram .
lastly , for your high blood pressure , it looks like you're managing it well at this time , okay ? so , i wan na go ahead and continue with the lisinopril 20 mg a day . i want you to continue to record your blood pressures at home , and report them to me in the patient portal if you see they're getting elevated , okay ?
[patient] mm-hmm .
[doctor] does that sound like a plan ?
[patient] that sounds fine .
[doctor] okay . um , i'm gon na be in touch with you after we get your test results , and we'll go from there , okay ?
[patient] sure .
[doctor] all right . hey , Sarah , finalize the note .

CHIEF COMPLAINT

Follow-up of chronic problems.

HISTORY OF PRESENT ILLNESS

Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow-up of his chronic problems.

The patient states he has been feeling out of sorts lately. He is not sure if it is due to the change in the seasons or due to performing lots of projects and some construction on his home. He reports fatigue and lightheadedness. This has been going on for about 5 weeks. While exerting energy, he has experienced some shortness of breath and chest cramps. The patient also notes a slight cough, but he is not sure if it is just the change in seasons.

He feels bloated every once in a while. His diet has been a little bit of a struggle. They had construction on their kitchen begin over Labor Day weekend, and have been eating less healthy food as a result.

Regarding his heart failure, he has been pretty good with his salt intake. He has been pretty good about his diet since the last year and is staying on top of that as much as possible. The patient has continued to utilize Lasix daily.

For his hypertension, this has been well controlled with lisinopril 20 mg a day. He has continued to monitor his blood pressure regularly.

The patient did the review of systems sheet when he checked in. He denies weight gain, swelling in the lower extremities, fevers, chills, dizziness, nausea, vomiting, and diarrhea.

REVIEW OF SYSTEMS

• Constitutional: Endorses fatigue. Denies fevers, chills, or weight loss.
• Cardiovascular: Endorses chest pain or dyspnea on exertion.
• Respiratory: Endorses cough and shortness of breath.
• Gastrointestinal: Endorses bloating.

PHYSICAL EXAMINATION

• Neck: JVD 8 cm.
• Respiratory: Rales bilateral bases.
• Cardiovascular: 3/6 systolic ejection murmur.
• Musculoskeletal: 1+ pitting edema bilateral lower extremities.

RESULTS

X-ray of the chest demonstrates a mild amount of fluid in the lungs.

Echocardiogram demonstrates decreased ejection fraction of 45% and mild mitral regurgitation.

ASSESSMENT AND PLAN

Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow up of his chronic problems.

Congestive heart failure.
• Medical Reasoning: The patient reports increased fatigue, dizziness, and chest discomfort on exertion. He also exhibits some jugular venous distention, lung base crackles, and lower extremity edema on exam today. He has been compliant with his current medications but admits to dietary indiscretion lately. His recent echocardiogram demonstrated a reduced ejection fraction of 45%, as well as mitral regurgitation.
• Additional Testing: We will order a repeat echocardiogram.
• Medical Treatment: Increase Lasix to 80 mg daily.
• Patient Education and Counseling: I advised the patient to monitor and record his daily weight and report those to me via the patient portal. He will contact me should he continue to experience any dyspnea.

Hypertension.
• Medical Reasoning: This is well controlled based on home monitoring.
• Medical Treatment: Continue lisinopril 20 mg daily.
• Patient Education and Counseling: I advised him to monitor and record his blood pressures at home and report these to me via the patient portal.

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


[doctor] hi , ms. thompson . i'm dr. moore . how are you ?
[patient] hi , dr. moore .
[doctor] hi .
[patient] i'm doing okay except for my knee .
[doctor] all right , hey , Sarah , ms. thompson is a 43 year old female here for right knee pain . so tell me what happened with your knee ?
[patient] well , i was , um , trying to change a light bulb , and i was up on a ladder and i kinda had a little bit of a stumble and kinda twisted my knee as i was trying to catch my fall .
[doctor] okay . and did you injure yourself any place else ?
[patient] no , no . it just seems to be the knee .
[doctor] all right . and when did this happen ?
[patient] it was yesterday .
[doctor] all right . and , uh , where does it hurt mostly ?
[patient] it hurts like in , in , in the inside of my knee .
[doctor] okay .
[patient] right here .
[doctor] all right . and anything make it better or worse ?
[patient] i have been putting ice on it , uh , and i've been taking ibuprofen , but it does n't seem to help much .
[doctor] okay . so it sounds like you fell a couple days ago , and you've hurt something inside of your right knee .
[patient] mm-hmm .
[doctor] and you've been taking a little bit of ice , uh , putting some ice on it , and has n't really helped and some ibuprofen . is that right ?
[patient] that's right . yeah .
[doctor] okay , let's review your past history for a second . it looks like , uh , do you have any other past medical history ?
[patient] uh , afib .
[doctor] okay , and are you taking any medications for that ?
[patient] yeah , i am . um , begins with a d.
[doctor] uh , digoxin ?
[patient] that's it . yeah , that's it .
[doctor] okay , all right . how about any surgeries in the past ?
[patient] i have had a nose job .
[doctor] all right . um , let's do your exam , okay ? so is it tender ... where is it mostly tender right now ?
[patient] right on the inside of my knee . right here .
[doctor] all right , so if i bend your knee forward , does that seem to hurt ?
[patient] yes , that hurts .
[doctor] all right , how about if i twist it a little bit that way .
[patient] that hurts a lot .
[doctor] okay , okay . and how about down here ? do you feel me touch you down here ?
[patient] yes .
[doctor] all right . any other pain down here in your calves ?
[patient] no .
[doctor] no , okay . so on exam you do have some tenderness over the medial portion of your knee over the medial meniscus area . uh , there is no , uh , there is a little bit of tenderness when i flex your , uh , when i , uh , uh , do some valgus stressing on your , on your leg . um , you have normal sensation . so let's take a look at your x-rays .
[patient] okay .
[doctor] okay . hey Sarah , show me the x-rays . so looking at the x-ray , um , of your left knee , uh , it appears to be there's no fractures there right now . i do n't see any , uh , there's a little bit of , uh , fluid , uh , but there is no , uh , there's no , um , fracture or there's no dislocation . everything else seems to be lined up properly , okay ?
[patient] okay .
[doctor] so in summary after my exam , uh , looking at your knee , uh , on the x-ray and your exam , you have some tenderness over the medial meniscus , so i think you have probably an acute medial meniscus sprain right now or strain . uh , at this point , my recommendation would be to put you in a knee brace , uh , and we'll go ahead and have you use some crutches temporarily for the next couple days . we'll have you come back in about a week and see how you're doing , and if it's not better , we'll get an mri at that time .
[patient] okay .
[doctor] i'm going to recommend we give you some motrin , 800 milligrams . uh , you can take it about every six hours , uh , with food . uh , and we'll give you about a two week supply .
[patient] okay .
[doctor] okay . uh , do you have any questions ?
[patient] no , i think i'm good .
[doctor] all right . hey , Sarah , order the medications and procedures discussed , and finalize the report . okay , come with me and we'll get you checked out .

CC:

Right knee pain.

HPI:

Ms. Thompson is a 43-year-old female who presents today for an evaluation of right knee pain. She states she was trying to change a lightbulb on a ladder, and she twisted her knee when she stumbled and caught herself from falling yesterday. She has been applying ice and taking Ibuprofen without relief.

CURRENT MEDICATIONS:

Ibuprofen, digoxin.

PAST MEDICAL HISTORY:

Atrial fibrillation.

PAST SURGICAL HISTORY:

Rhinoplasty.

EXAM

Examination of the right knee shows pain with flexion. Tenderness over the medial joint line. No pain in the calf. Pain with valgus stress. Sensation is intact.

RESULTS

X-rays of the right knee show no obvious signs of acute fracture or dislocation. Mild effusion is noted.

IMPRESSION

Right knee acute medial meniscus sprain.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a knee brace. She will take Motrin 800 mg, every 6 hours with food, for two weeks. She will use crutches for the next couple of days. She will follow up with me in 1 week for a repeat evaluation. If she is not better at that time, we will obtain an MRI. All questions were answered.