[doctor] hey george how are you today i understand you're here for some numbness and tingling in your fingers and some pain in your wrist
[patient] right my left wrist and hand has been bothering me probably for a few months now with pain and numbness
[doctor] okay and you said that's been ongoing for several months do you know what caused this type of pain or is it just something that started slowly or
[patient] it just kinda started on it's own it i notice it mostly at night
[doctor] okay
[patient] sometimes it will i'll wake up and my hands asleep and i got ta shake it out
[doctor] shake it out and okay
[patient] and then some
[doctor] what kind of work do you do
[patient] i do yard work
[doctor] yard work
[patient] landscaping landscaping
[doctor] landscaping okay so a lot of raking a lot of digging so a lot of repetitive type movements
[patient] yeah it's pretty heavy labor but it's yeah the same thing day in and day out
[doctor] okay okay just a couple questions for you you did say that you have the pain at night in that and you have to you get that numbness into the hand is it in all the fingers
[patient] yeah it seems to happen to all my fingers but i notice it more in my thumb and pointer finger
[doctor] okay okay and anything into that little into your fifth finger your little finger any numbness there at times no
[patient] sometimes yeah it seems like it's numb too
[doctor] okay what about your right hand any problems with that hand
[patient] no i do n't seem to have any problems with my right hand so far it's just mostly my left
[doctor] okay okay good and just a couple you know do you how do you have many or do you drink often do you have you know many any alcohol consumption
[patient] i drink usually a a beer or two on fridays and saturdays on the weekends
[doctor] okay and do you have any evidence of any anybody ever said that you had some rheumatoid arthritis in your hand or wrist anything like that
[patient] no nobody say anything like that so i mean
[doctor] okay okay good so let me go ahead and do a physical exam here real quick and you know i'm gon na quickly just listen to your heart and lungs okay that's good i'd like you to squeeze i'm gon na hold your hands here and i'd like you to squeeze both hands
[patient] okay
[doctor] you seem a little bit weaker on that left hand is that what you've noticed
[patient] yeah i i i experienced some weakness in my left hand
[doctor] okay do you you find that you're dropping things when you're picking it up is it to that level or
[patient] yeah i drop things mostly because i have a hard time feeling it
[doctor] okay okay good and so you you do have a a grip strength is less on the left and i just wan na touch your fingers here on the on the right side you can feel me touching all the fingers on the right
[patient] yeah i can i can say you touch me but it feels a little more weird on the thumb side than my pointer finger side
[doctor] okay okay and i wan na turn your wrist over here and turn your hand over and i'm gon na go ahead and tap on the right wrist on the back here does that do anything when i do that
[patient] i still i feel a little jolt or a zing in my finger tips
[doctor] okay and then when i do that on the left side
[patient] yeah same thing
[doctor] same thing okay so you do have a bilateral positive tinel's sign so so here's here's where i'm at i think your your diagnosis is beginning to have some bilateral carpal tunnel syndrome usually we see that with repetitive actions such as the landscaping the heavy labor and you you know your your clinical exam and and history sound like it's a carpal tunnel syndrome i do want to order so where are we gon na go from here i would like to order a a study it's called an emg where it it measures some of that electrical impulses down into your fingers we will follow up with that but as far as your treatment so the treatment for carpal tunnel syndrome is really some activity modification now i know you are a landscaper is there any way that you could be work to have some lighter work during the time
[patient] i suppose i could try to pass it off to some of my other employes and delegate
[doctor] okay that would be good so that's i i just want you to kinda eliminate that the active repetitive motions that you're doing all the time just for a couple weeks i'm also gon na give you a wrist splint to wear and that should help and i'd like you to take ibuprofen six hundred milligrams every six hours and then i wan na see you back here in the office in two weeks and in that two week period i think we're gon na see if there's need for any other intervention if i need to do more diagnostic testing or if there is a possibly looking at a surgical intervention to release that pressure that's on the nerves in that hand does that sound like a a good plan for you
[patient] yeah it sounds like a good first start
[doctor] okay okay so i i just just off off the record here what kind of what do what do you specialize in landscaping is your company do
[patient] mostly like yard work and maintenance flower beds not really designing just up keep
[doctor] okay yeah i'm looking for a landscape designer i need somebody to put in some elaborate walkways back through the backyard so yeah we can do stuff like that i mean if you have an idea what you want i think that's easy
[patient] okay
[doctor] you know if you're looking for like some
[patient] backyard elasis rehab remodel that's i mean i suppose we could do we have n't done things like that in a while because we're busy enough with just the up key but it's something to explore
[doctor] okay yeah i may have to keep that in mind because i do wan na do some of that so let's listen i'm gon na get my my nurse in here to discharge you do you have any other questions for me before we end this
[patient] no i think it's all clear i appreciate it
[doctor] okay take care and i'll look forward to see you in two weeks
[patient] very good appreciate your time

CHIEF COMPLAINT

Left wrist and hand pain.

HISTORY OF PRESENT ILLNESS

George Lewis is a pleasant 57-year-old male who presents to the clinic today for evaluation of left wrist and hand pain. He reports an onset of a few months ago but denies any specific injury. However, the patient notes he often engages in repetitive motions while performing his work duties. His symptoms are worse at night, and he wakes with numbness in the bilateral hands. He experiences numbness in all fingers, but states it is the most noticeable in the left thumb and index finger. He affirms intermittent numbness in the left little finger. For relief, he shakes his hands upon waking. The patient also experiences weakness in his left hand. He reports he drops objects and explains “I have a hard time feeling it.”

MEDICAL HISTORY

The patient denies a history of rheumatoid arthritis.

SOCIAL HISTORY

He works in landscaping. He reports consuming 1 to 2 beers on weekends.

REVIEW OF SYSTEMS

Musculoskeletal: Reports left wrist and hand pain. Denies right hand pain.
Neurological: Reports numbness in bilateral hands and fingers, and left hand weakness.

PHYSICAL EXAM

NEURO: Decreased sensation in the right thumb and index finger.
MSK: Examination of the bilateral hands: Grip strength is less on the left in comparison to the right. Positive Tinel sign bilaterally.

ASSESSMENT

Bilateral carpal tunnel syndrome.

PLAN

After reviewing the patient's clinical history and examination today, I have had a lengthy discussion with him regarding treatment options for his current symptoms. I discussed the importance of activity modification and encouraged the patient to limit active repetitive motions while working for the next 2 weeks. I also recommended that he wear a wrist splint to provide increased support. I advised him to take ibuprofen 600 mg every 6 hours. Additionally, I recommended we obtain an EMG of the bilateral upper extremities to evaluate for carpal tunnel syndrome. The patient will follow up with me in 2 weeks when the EMG results are available for review. If at that time his symptoms have not improved with these conservative measures, we will discuss further treatment options including additional diagnostic testing or possible surgical intervention.

The patient states he understands and is in agreement with the plan. All questions were answered to the patient's satisfaction.

INSTRUCTIONS

The patient will follow up with me in 2 weeks.


[doctor] hi billy how are you what's been going on the medical assistant told me that you're having some difficulty urinating
[patient] yeah yeah i i did n't really wan na come in to talk about it's kinda weird but i think probably over the last six months i'm just not peeing right it just does n't seem to be normal
[doctor] okay so let's talk a little bit about that now is your is your stream is your urination stream weak
[patient] yeah i'd probably say so
[doctor] okay and do you feel like you're emptying your bladder fully or do you feel like you still have some urine left in there when you when you finish
[patient] most of the times i'm okay but sometimes if i stand there long enough i i can kinda go a little bit more so it's taking a while actually to just go to the bathroom
[doctor] okay and are you waking up at night to go to the bathroom does it impact your sleep
[patient] yeah i try to empty my bladder now right before i go to bed and and not drink anything but i'm still probably getting up three or four times a night to go to the bed
[doctor] okay so you're getting up about three or four times a night and and how long has this been going on you said for about six months
[patient] yeah six months to like this and it's probably been a little bit worse over the last six months and maybe it's been longer i just did n't want to bring it up
[doctor] okay so you think it's been going on longer okay alright now how about have you had any burning when you urinate at all
[patient] no it i do n't think it burns
[doctor] no burning when you urinate okay and and any other any other issues any problems with your bowels any constipation issues
[patient] hmmm no i i i had diarrhea last week but i think i ate something bad
[doctor] okay and ever have you ever had any issues where you had what we call urinary retention where you could n't pee and you needed to have like a catheter inserted
[patient] my gosh no
[doctor] okay
[patient] i'll do that
[doctor] alright and have you ever seen a urologist i do n't think so you've been my patient for a while i do n't remember ever sending you but have you ever seen one
[patient] i do n't think so
[doctor] okay now tell me how are you doing with your with your heart when was the last time you saw doctor moore the cardiologist i know that you had the the stent placed in your right coronary artery about what was that twenty eighteen
[patient] yeah sounds about right i think i just saw him in november he said everything was okay
[doctor] he said everything was okay alright and so you have n't had any chest pain or shortness of breath you're still walking around doing your activities of daily living are you exercising
[patient] kind of
[doctor] kind of okay now from what i remember i remember you being a big college football fan are you as excited as i am that georgia beat alabama in the national championships
[patient] yeah yeah i'm super excited
[doctor] you do n't really seem that excited
[patient] get the problem fixed because i have to be able to sit there and watch the whole game
[doctor] yeah i i really do n't like nick saving i'm so i'm super happy that that the dogs pulled it out
[patient] i do n't know if we can do friends anymore
[doctor] are you in alabama fan
[patient] maybe i'm actually originally not from georgia so
[doctor] okay alright well i mean i i'm i'm a long horns fan but anyway well i digress let's talk a little bit about your diabetes how are how are you doing with your sugars are you watching your diet
[patient] i'm trying to yeah i think they are okay
[doctor] okay and are you still taking the metformin
[patient] yep
[doctor] you are okay alright now i wan na go ahead and just move on to a quick physical exam okay i'm gon na be calling out some of my exam findings and i'm gon na let you know what that means when i'm done okay alright i do have to do a rectal exam i apologize i'm just gon na be calling it out what what i what i appreciate okay so on your heart exam i do appreciate a slight three out of six systolic ejection murmur hurt at the left base on your lung exam your lungs are clear to auscultation bilaterally on your abdominal exam your abdomen is nontender and nondistended i do n't appreciate any masses or any rebound or guarding on your prostate exam i do appreciate an enlarged prostate i do n't appreciate any masses on physical exam so what what does that mean billy so that ultimately means that you know everything looks good you know you have that little heart murmur which i believe you you've had in the past but we're gon na go ahead and look into that you know your prostate seems a little bit enlarged to me on physical exam so let's talk about how we can go about and and remedy that okay so for your first problem of this you know difficulty urinating i wan na go ahead and just order some routine labs i wan na get a a psa that kind of that ultimately kinda looks for prostate cancer issues which i do n't think you have because we did n't really appreciate that on physical exam i wan na go ahead and we can try to start you on what we call flomax zero point four milligrams once a day you should take it at night because it can cause people to get a little bit dizzy if they take it in the morning so i would take it at night and i wan na go ahead and refer you to a urologist just to look into this more so we can go ahead and and get this problem solved for you okay i'm also gon na go ahead and just order some routine blood tests just to make sure that we are not missing anything do you have any questions about that and i wan na go ahead and order a urinalysis and a urine culture
[patient] yeah so sounds good have you seen that commercial for that super batter prostate stuff does that work
[doctor] well i think the data it's it's i'm not really sure if it works or not i'm not that familiar with it let's just go ahead and stick with flomax and that's why we are gon na refer you to the urologist so that they can go ahead and talk to you about you know the most current treatment options for you okay
[patient] alright
[doctor] alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that
[patient] nope
[doctor] okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns
[patient] alright when is the urologist gon na call me
[doctor] i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week
[patient] sounds good
[doctor] okay alright well great it was good to see you bye
[doctor] i could just hit it and i can just talk and then i'm just

CHIEF COMPLAINT

Difficulty urinating.

MEDICAL HISTORY

Patient reports history of coronary artery disease and diabetes.

SURGICAL HISTORY

Patient reports undergoing right coronary arter stent placement in 2018 by Dr. Moore.

SOCIAL HISTORY

Patient reports that he tries to exercise. He is a college football fan.

REVIEW OF SYSTEMS

Cardiovascular: Denies chest pain or shortness of breath.
Gastrointestinal: Denies change in bowel movements.
Genitourinary: Reports difficulty urinating. Denies dysuria or urinary retention.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
Slight 3/6 systolic ejection murmur heard at the left base.

Gastrointestinal
- Examination of Abdomen: Nontender and nondistended. No masses, rebound or guarding.

Rectal
- Examination: Enlarged prostate appreciated. No masses appreciated.

ASSESSMENT AND PLAN

1. Difficulty urinating.
- Medical Reasoning: The patient presents today with approximately a 6 month history of difficulty with urination. His prostate also felt slightly enlarged on exam today.
- Patient Education and Counseling: The patient was advised that there were no concerning symptoms of prostate cancer appreciated on his physical exam today.
- Medical Treatment: We will order routine labs including a PSA to rule out prostate cancer. We will also refer him to a urologist for further evaluation as well as order a urinalysis and urine culture. We will start him on Flomax 0.4 mg once at night to avoid dizziness.

2. Coronary artery disease.
- Medical Reasoning: The patient had a 3/6 systolic ejection murmur heard at the left base on exam today. This has been heard on his exams in the past.
- Medical Treatment: We will order an echocardiogram to follow up on his murmur. We will also order a lipid panel. He will continue Lipitor 40 mg a day, aspirin and metoprolol.

3. Diabetes.
- Medical Reasoning: The patient is currently doing well with his diabetes.
- Medical Treatment: We will continue him on metformin 1000 mg twice a day. A hemoglobin A1c will be ordered to see if any medication adjustments are needed.

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

INSTRUCTIONS

He will follow up in 3 to 4 weeks and is advised to call or message me in the patient portal if he has any concerns.


[doctor] hi russell how are you what's been going on
[patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days
[doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee
[patient] yeah it kinda burns a little bit
[doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay
[patient] okay
[doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you

CHIEF COMPLAINT

Right-sided abdominal pain

MEDICAL HISTORY

Patient reports history of kidney stones.

FAMILY HISTORY

Patient reports his father has a history of kidney stones.

MEDICATIONS

Patient reports use of Tylenol.

REVIEW OF SYSTEMS

Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting
Genitourinary: Reports dysuria and dark colored urine. Denies hematuria.

PHYSICAL EXAM

Gastrointestinal
- Examination of Abdomen: No masses or tenderness to palpation. No rebound or guarding. No peritoneal signs. Positive CVA tenderness on the right flank.

RESULTS

Previous CT scan of the abdomen ordered by the patient's PCP is reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter. There is no evidence of hydronephrosis.

ASSESSMENT AND PLAN

1. Acute nephrolithiasis.
- Medical Reasoning: The patient presents with complaints of right-sided abdominal pain. His previous CT scan was reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter without evidence of hydronephrosis.
- Medical Treatment: I have recommended that he push fluids in order to help facilitate urination to help pass the stone. He will be provided with a strainer to allow us to potentially test the stone if he is able to pass it. I have also prescribed oxycodone 5 mg every 6 to 8 hours as needed for pain. He can continue to alternate oxycodone with Tylenol. A basic metabolic panel, urinalysis, and urine culture will also be ordered.

INSTRUCTIONS

He will follow up in 1 to 2 weeks. If he is still having symptoms at that time, we will discuss further treatment such as lithotripsy or ureteroscopy. He is to contact me if he is having worsening symptoms over the next week.


[doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three non-small cell lung cancer who presents for follow-up during neo agit chemotherapy she was diagnosed with a four . four centimeter left upper lobe nodule biopsy was positive for adenocarcinoma molecular testing is pending at this time alright hello beverly how are you
[patient] i'm good today
[doctor] you're good today yeah you've been going through a lot lately i know you just had your treatment how how are your symptoms
[patient] my symptoms are pretty good today i just kind of have a minimal cough and a sore throat
[doctor] okay
[patient] but that's all i'm feeling today
[doctor] okay and how about fatigue have you been feeling more tired
[patient] yes a little bit
[doctor] okay and how about any nausea or vomiting
[patient] no not as of today
[doctor] okay and i know you were mentioning a cough before how is it as far as walking are you having any shortness of breath
[patient] i have n't noticed any shortness of breath it just kind of seems to be a lingering kind of light dry cough
[doctor] cough okay is it any mucus with it or is it a dry cough
[patient] more dry
[doctor] a dry cough okay and tell me more about this sore throat
[patient] this kind of seems to be persistent comes and goes it will be worse sometimes and then others it feels better trying to drink lots of fluids
[doctor] okay
[patient] to see if it can it you know the dry coughing if it's part of that or what i can do
[doctor] okay and when you mention drinking and eating is do you feel like anything is getting stuck there
[patient] no i do n't feel like anything is getting stuck right now and i have n't been i have been eating but not as much as i normally would
[doctor] okay okay alright and how are you doing as far as like just emotionally and mentally how are you doing i'm just talking a little bit about your support systems
[patient] the nursing staff and the office has been very good to help you know with anything that i need as far as support so just since we are just getting started so far on the journey i do feel like i have support and mentally you know still feel strong
[doctor] okay and how about with family or friends have you been able to turn to anyone
[patient] i do have good family members that have been supportive and they have come to my treatment with me
[doctor] okay excellent excellent and so right now you're on a combination of two different chemotherapies the cisplatin as well as the etoposide and you had your last treatment just a few days ago but you're saying right now you've been able to tolerate the nausea and the fatigue
[patient] yes i have n't had any nausea but you know just slight fatigue it does n't seem to be overwhelming
[doctor] okay okay so we are gon na go ahead if it's okay with you and start your physical exam reviewing your vitals so vitals look good especially your oxygen especially with the chemotherapy you've been getting and the cough so your oxygen looks good so i'm happy with that so now i'm just examining your neck especially with your sore throat and i do n't appreciate any cervical lymphadenopathy and also no supraclavicular adenopathy listening to your heart you have a nice regular rate and rhythm with no murmurs that i appreciate now on your lung exam when you're taking some deep breaths i do notice some crackles in your lungs bilaterally and what that means is there is there is some faint sounds that i'm hearing which could represent some fluid there so on looking at your skin exam on your chest you do have some erythema on the anterior side of the chest on the left side and this could be related to the radiation so on your lower extremities i appreciate no edema and everything else looks good and thank you i know you did a chest x-ray before coming in so on your results for the chest x-ray it does look like you have some mild radiation pneumonitis which basically means some inflammation of the lungs most likely due to the radiation so what does this all mean so for your assessment and plan so for the first diagnosis the first problem of the lung cancer so what we're gon na do is we're gon na continue with the current regimen of your chemotherapy of the cisplatin and etoposide and the etoposide and we're gon na continue with your current dose of radiation at forty five gray and when that's complete we will repeat some imaging and hopefully you know the tumor will shrink down enough that we can remove it surgically okay for problem number two so the radiation pneumonitis so that's what causing that cough as well as some of the shortness of breath i know you're not experiencing it much now so what i'm gon na do for that is actually gon na prescribe you a low dose of prednisone and so that's an will help with the inflammation i'm gon na give you forty milligrams daily for five days and so hopefully that will help reduce the inflammation and so that you can continue with the radiation okay how does that sound so far
[patient] that sounds great thank you
[doctor] okay and then lastly for the painful swallowing that you're having so the inflammation you're having it not only in your lungs but it also in your esophagus as well so what i'm gon na do is prescribe you you're taking the the prednisone i'm also gon na give you a lidocaine swish and swallow and you can do that four times a day and so that will be able to help you so you can eat immediately after taking it and it can also help so that you can continue to take food and fluids prevent dehydration and any further weight loss
[patient] great
[doctor] okay any questions for me
[patient] i do n't believe so at this time
[doctor] okay alright so i'll see you at your next visit
[patient] great thank you
[doctor] you're welcome and so now just

CHIEF COMPLAINT

Follow up of stage III non-small cell lung cancer.

MEDICAL HISTORY

Patient reports history of stage III non-small cell lung cancer.

SOCIAL HISTORY

Patient reports having a good family support system and that some of her family has accompanied her to her chemotherapy sessions.

MEDICATIONS

Patient reports she is currently receiving chemotherapy treatment consisting of Cisplatin and etoposide.

REVIEW OF SYSTEMS

Constitutional: Reports fatigue and decrease in appetite.
HENT: Reports sore throat. Denies dysphagia.
Respiratory: Reports dry cough. Denies shortness of breath.
Gastrointestinal: Denies nausea or vomiting

VITALS

Vitals are within normal limits including oxygen saturation.

PHYSICAL EXAM

Neck
No cervical lymphadenopathy or supraclavicular adenopathy.

Respiratory
- Auscultation of Lungs: Crackles heard bilaterally.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs.

Musculoskeletal
- Examination: No edema.

Integumentary
- Erythema noted on the anterior side of the chest on the left side possibly related to radiation.

Hematology/Lymphatic/Immunology
- Palpation: No enlarged lymph nodes.

RESULTS

Chest x-ray is reviewed and demonstrates mild radiation pneumonitis.

ASSESSMENT AND PLAN

1. Stage III non-small cell lung cancer.
- Medical Reasoning: The patient has a recent diagnosis of stage III non-small cell lung cancer. Biopsy was positive for adenocarcinoma. Molecular testing is pending at this time.
- Medical Treatment: We are going to continue with the current regimen of combination chemotherapy consisting of Cisplatin and etoposide. We are also going to continue with her current dose of radiation at 45 Gy. Once this is complete, we will obtain repeat imaging in hopes that the tumor will decrease in size enough for surgical removal.

2. Radiation pneumonitis.
- Medical Reasoning: The patient is experiencing a persistent dry cough. Recent x-rays are reviewed and demonstrated evidence of mild radiation pneumonitis.
- Patient Education and Counseling: We discussed the etiology of her dry cough is from her mild radiation pneumonitis.
- Medical Treatment: A prescription of prednisone 40 mg daily for 5 days is provided to help with her inflammation.

3. Painful swallowing.
- Medical Reasoning: The patient is experiencing painful swallowing secondary to inflammation of the esophagus.
- Patient Education and Counseling: We discussed the etiology of her painful swallowing and that a lidocaine viscous solution will be beneficial in preventing dehydration and any further weight loss.
- Medical Treatment: A lidocaine viscous solution was provided to be performed 4 times daily.

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

INSTRUCTIONS

The patient will return to clinic at her next scheduled follow up.


[doctor] hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that
[patient] yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some burning and some stinging and looked down and saw a blister i did n't think too much of it because it was on the pad of the bottom of my foot around my heel and i just had been walking on the front part of my foot i started to notice a foul smell and my wife mentioned something to me the other day and i noticed my dog was also smelling my socks a lot and so we looked and saw that the blister had become unroofed or the the top part of the skin of the blister became undone and then underneath it was just this really thick soft mushy skin that had a bad smell with some yellow drainage and so and barbara called the primary care doctor who then got me in to see you he started me on some antibiotics about six days ago and i never had any nausea or vomiting but my wife checked my temperature it was about ninety nine point seven and then at one point i had to put on an extra blanket in bed because i had some chills and when i started the antibiotics it started to feel pretty good but we've now noticed that it has turned black around the outside of the wound and i'm getting some cramping in my calf muscle as well and so there was a red streak also that was coming up the front part of my my ankle along the inside portion of my calf muscle and it's super super hot and so they wanted me to take a have have you look at it
[doctor] okay thank you for sharing that history with me and did you complete that course of antibiotics
[patient] i think he called in ten days' worth and i'm on day six or seven right now i know i've got about two or three days left
[doctor] okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now
[patient] yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point
[doctor] okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that
[patient] yeah my my a1c is six point seven it's pretty well controlled
[doctor] okay
[patient] i used to be on an insulin pump and i had an a1c that at one point was like thirteen but we worked with an endocrinologist to get it down to where it's at now i've been six point seven for probably two years now and i rarely have a blood sugar that goes over two hundred i check two or three times a day if i feel weird i'll check it again but i noticed my sugars have probably been trending in the three to four hundreds the last two weeks and then i had one spike at one point at like five or six hundred that got our attention and i think that's also what made my wife call the primary care doc
[doctor] okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park
[patient] yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now
[doctor] absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there
[patient] i do n't feel that right there
[doctor] okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure
[patient] no not really so you're gon na continue the antibiotics that i'm on and possibly extend or call in a new antibiotic depending on the culture
[doctor] correct
[patient] if i heard
[doctor] yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy
[patient] okay sounds good
[doctor] alright

CHIEF COMPLAINT

Non-healing ulcer on his right foot.

HISTORY OF PRESENT ILLNESS

Nicholas Gutierrez is a pleasant 45-year-old male who presents to the clinic today for the evaluation of a non-healing ulcer on his right foot. The patient was referred from his primary care physician. The onset of his pain began 6 weeks ago, after wearing a pair of shoes that were too tight.

Today, he describes a burning, stinging, and throbbing sensation. The patient reports a blister on the pad of the plantar aspect of his foot around his heel. He explains that he has been ambulating on the anterior aspect of his foot. He explains that the top part of the skin of the blister detached, which revealed a thick, soft, mushy skin associated with unpleasant smell and yellow drainage. The patient called his primary care physician, who referred him to our office. He was prescribed a 10-day course of antibiotics approximately 6 days ago. He experienced chills and a fever of 99.7 degrees Fahrenheit. The patient denies any nausea or vomiting. He states that when he started the antibiotics, his foot began to feel pretty good. However, he has now noticed that his foot has turned black around the outside of the wound, and he is experiencing cramping in his calf muscle as well. He also reports a burning red streak that was coming up the front part of his ankle along the inside portion of his calf muscle. While palpating his calf, he has noted stiffness in the muscle that is now up to the patella. The patient reports that he has been coughing a lot over the last 2 days. He has experienced shortness of breath with ambulation around the house. He reports that he purchases new diabetic shoes yearly and changes the inserts every 3 to 4 months.

The patient is diabetic and has diabetic neuropathy. He explains that his blood sugar has been trending in the 300 to 400's over the last 2 weeks. At one point, he had a blood sugar spike to either 500 or 600. He states that his last hemoglobin A1c was 6.7, which has been his average for approximately 2 years. The patient checks his blood sugar 2 to 3 times per day and rarely has a blood sugar that goes over 200. He explains that he used to be on an insulin pump and had an A1c that at one point was 13. He states that he worked with an endocrinologist to get it down to where it is now.

MEDICAL HISTORY

The patient reports a history of diabetic neuropathy.

SOCIAL HISTORY

The patient enjoys hiking.

REVIEW OF SYSTEMS

Constitutional: Reports subjective fever and chills
Respiratory: Reports cough and shortness of breath with ambulation.
Gastrointestinal: Denies nausea and vomiting.
Musculoskeletal: Reports right foot pain and right calf cramping.
Skin: Reports right foot ulcer with yellow foul smelling drainage, and red streaking coming up the front part of his ankle along the inside portion of his calf muscle.

VITALS

Temperature is slightly elevated.
Vitals are otherwise good.

PHYSICAL EXAM

CV: Edema and pain in calf. Bilateral palpable femoral and papiteal pulses are present. I do not recognize a palpable dorsalis pedis or posterior tibial pulse; however, they are present via Doppler.
MSK: Examination of the right foot: The necrotic wound on his heel is present. It is approximately 2 cm x 2 cm. I do recognize the sloughing of the tissue, as well as what looks like cellulitis around the area, and erythema. An odor is present from the wound. I do not appreciate any bony exposure now. No pain to palpation in the effected area.

RESULTS

3 views of the right foot were taken today. These reveal no evidence of osteomyelitis or infection.

ASSESSMENT

Right non-healing diabetic foot ulcer.
Diabetes.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed.

In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results.

INSTRUCTIONS

The patient will follow up with me in 7 days to check on his progress.


[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] 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 passes 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] so sophia i see that you you hurt your knee tell me about what happened
[patient] yeah i was jumping on my kid's trampoline and i could just slipped out from under me
[doctor] my gosh one of those big trampolines in your back yard
[patient] yeah a pretty big one
[doctor] okay which knee was it
[patient] my right knee
[doctor] right knee okay and when did this happen
[patient] about four days ago
[doctor] great the weather was perfect this weekend so i'm glad you at least got outside sorry to hear you got hurt okay so your right knee did you did you feel it like pop or or snap or anything when you hurt it
[patient] yeah i felt a little pop and then it swelled up really big afterward
[doctor] okay did you try anything for the pain
[patient] i took some ibuprofen and i put some ice on it
[doctor] okay did that help
[patient] a little bit but it's still really hard to get around
[doctor] alright and have you have you been able to stand on it or does that hurt too much
[patient] it hurts quite a bit to stand but i am able to put weight on it
[doctor] okay alright and what part of the knee is it inside outside middle
[patient] kind of that inside part of my kneecap
[doctor] okay alright and okay so as long as you're here and then your primary care physician i'm looking through your chart and it looks like we're treating your diabetes so how you've been doing with your your diet overall are you are you keeping your sugars low
[patient] it's going okay i i forget to check quite a bit though
[doctor] sure
[patient] on it
[doctor] yeah i understand how has your diet been lately
[patient] it's been pretty good
[doctor] okay okay good good you know it's hard to stay away from the sugary foods sometimes i i enjoy ice cream regularly okay so let's do physical exam as long as you are here so i'm just gon na listen to your heart your heart sounds normal no murmurs or gallops listen to your lungs quick if you can take a deep breath lungs are clear that's good news let's take a look at that knee right knee looks like it definitely has some swelling i'm gon na do some maneuvers here does it hurt when i push you on the inside of the knee
[patient] yeah that hurts
[doctor] okay how about the outside
[patient] a little bit but not as much
[doctor] okay so some pain on palpation on the inside little bit of pain on the outside of the knee if i bend the knee back does that hurt
[patient] yeah
[doctor] how about when i extend it
[patient] yeah that hurts
[doctor] okay so little bit of limited range of motion as well as pain on both flexion and extension on the knee i'm gon na push on this a little bit looks like your mcmurray's test is negative just checking for a meniscus tear okay so let's talk a little bit about your plan what i am concerned about for your knee is it sounds like you have a torn or injured mcl i it's that inside tendon in your knee so i'm concerned about that since you're having trouble with weightbearing and you heard that pop so what i'm gon na do is i'm gon na put you in a straight leg brace and i'll prescribe some mobic you can start taking that as a a pain reliever and to try to get some of the swelling down i want you to ice your knee once an hour for about fifteen minutes but i'm also gon na send you out for an mri because we wan na make sure this is what happens see if there's any other damage to the knee does that sound good
[patient] yeah that sounds great thank you
[doctor] yeah and then for your diabetes as long as you're here it sounds like you're managing that pretty well but i do wan na get a recheck on your hemoglobin a1c and then i'm also i'm going to get a refill on the metformin that you have been taking five hundred milligrams so you can keep taking that as well so do you have any other questions for me
[patient] no that's it thanks
[doctor] alright well thank you hope that you feel better

CHIEF COMPLAINT

Right knee pain.

MEDICAL HISTORY

The patient has a history of diabetes. She has been doing pretty good with her diet. She states that she forgets to check her sugars quite a bit.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain and swelling.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
No murmurs, gallops.

Musculoskeletal
- Examination of the right knee: Some swelling present.
- Palpation: Some pain to palpation on the medial aspect of the right knee, and a little bit of pain on the lateral aspect of the right knee.
- Range of Motion: Limited range of motion as well as pain on both flexion and extension of the knee.
- Special Testing:
McMurray's Test: Negative.

ASSESSMENT AND PLAN

1. Right knee pain.
- Medical Reasoning: I am concerned about a torn MCL due to pain on ambulation and trouble with weightbearing, as well as the pop she heard.
- Patient Education and Counseling: We discussed treatment options today including bracing, anti-inflammatories, and icing. - Medical Treatment: I am going to put her in a straight leg brace and I will prescribe some Mobic. She can start taking that as a pain reliever and to try to get some of the swelling down. I want her to ice her knee once an hour for about 15 minutes.
- Additional Testing: I am also going to send her out for an MRI.

2. Type 2 diabetes.
- Medical Reasoning: The patient states that her type 2 diabetes are well-managed.
- Medical Treatment: I am also going to get a refill on the metformin that she has been taking 500 mg.
- Additional Testing: We are going to recheck her hemoglobin A1c.

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


[doctor] hey philip good to see you today so take a look here at my notes i see you're coming in for some right knee pain and you have a past medical history of hypertension and we will take a look at that so can you tell me what happened to your knee
[patient] yeah i was you know i was just doing some work on my property and i i accidentally slipped and fell down and i just still having some knee issues
[doctor] okay well that that's not good do you
[patient] no
[doctor] what part of your knee would you say hurts
[patient] i would just say you know the it it you know it basically when i when i'm flexing my knee when i'm moving it up and down and i put pressure on it
[doctor] alright did you hear a pop or anything like that
[patient] i did feel something pop yes
[doctor] okay and did it was it swollen afterwards or is it looks a little bit swollen right now
[patient] yeah little bit swollen yeah
[doctor] okay so so far have you taken anything for the pain
[patient] just taking some ibuprofen just for some swelling
[doctor] okay that's it what would you say your pain score is a out of ten with ten being the worst pain you ever felt
[patient] i would say that when i'm stationary i do n't really feel a lot of pain but if i start doing some mobility i would say probably a four five
[doctor] about a four okay and how long ago did you say this was is this happened this injury
[patient] it's been a week now
[doctor] a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly
[patient] yes i have
[doctor] okay so you might have a little white coat syndrome i know some of my patients definitely do have that so what about your diet i know we talked a little bit before about you reducing your sodium intake to about twenty three hundred milligrams per per day i know you were during the pandemic your diet got out of little bit out of control so how have you been doing how have you been doing with that
[patient] i definitely need some help there i have not have not made some some changes
[doctor] okay yeah we definitely need to get you to lower that salt intake get your diet a little bit better because the hope is to get you off that medication and get your blood pressure to a manageable level okay so we yeah we definitely can talk about that alright so lem me take a look at your knee i'll do a quick physical exam on you and before i do just want to make sure you're not having any chest pain today
[patient] no
[doctor] are you any belly pain
[patient] no
[doctor] no shortness of breath just wan na make sure
[patient] no
[doctor] okay so i'm just gon na listen to your lungs here your lungs are clear bilaterally i do n't hear any wheezes or crackles listen to your heart so on your heart exam i do still hear that grade two out of six systolic ejection murmur and you already had that and so we we knew about that already so lem me look at your knee here so when i press here on the inside of your knee does that hurt
[patient] a little bit
[doctor] little bit how about when i press on the outs the outside gon na press on the outside is that painful
[patient] no
[doctor] no alright so i'm gon na have you flex your knee is that painful
[patient] yeah that's uncomfortable
[doctor] that's uncomfortable and extend it so that's painful
[patient] yeah yes
[doctor] okay so on your knee exam i i see that you do have pain to palpation of the medial aspect of your right knee you have some pain with flexion extension i also identify some edema around the knee and some effusion you have a little bit of fluid in there as well so prior to coming in we did do an x-ray of that right knee and luckily you did n't break anything so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you have what we call a mcl strain so a medial collateral ligament strain so when you fell i think you twisted a little bit and so it irritated you strained that that ligament there so for that what we can do for you first i'm gon na prescribe you some ibuprofen eight hundred milligrams and you can take that twice a day and that's gon na help you with that swelling and that pain that you currently do have i'm also gon na put you in a a knee brace just to try and support those muscles to allow it to heal and then i want you to ice the knee you can do that for twenty minutes at a time for three to four times a day that should also help with the the swelling of your knee for your hypertension now i'm gon na keep you on that twenty of lisinopril okay because you are taking it and you you're doing pretty good with it i also want to get you a referral to nutrition just to try to help you with that diet you know because right now you are your diet is little bit out of control so we just need to rain you in a little bit and hopefully you know with their help we can eventually get you off that lisinopril alright so do you have any questions for me
[patient] do i need to elevate my leg or stay off my leg or
[doctor] yeah i would yeah you can elevate your leg stay off your stay off your leg you know if you have any kids have them work out in the yard instead of you just to to for a couple of weeks it's a good thing if you want to do that
[patient] tell him this doctor's order
[doctor] tell definitely tell him his doctor tell him i said it
[patient] alright do you have any other questions no that's it i appreciate you seeing me
[doctor] alright so my nurse will be in with the those orders and we will see you next time

CHIEF COMPLAINT

Right knee pain.

REVIEW OF SYSTEMS

Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Gastrointestinal: Denies abdominal pain.
Musculoskeletal: Reports right knee pain.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally. No wheezes.

Cardiovascular
- Auscultation of Heart: Grade 2/6 systolic ejection murmur. Some edema and effusion noted around the right knee.

Musculoskeletal
- Examination: Right knee
- Palpation: Pain to palpation of the medial aspect. No pain to palpation of the lateral aspect.
- ROM: Pain with flexion and extension.
-Some effusion noted around the right knee.

RESULTS

X-rays of the right knee were taken. These show no fractures or bony abnormalities.

ASSESSMENT AND PLAN

1. Right knee MCL strain.
- Medical Reasoning: Based on the physical examination findings, the patient has a MCL strain of the right knee. - Medical Treatment: I have prescribed ibuprofen 800 mg twice a day. I will also place him in a knee brace. I advised him to ice the knee for 20 minutes at a time for 3 to 4 times a day. The patient was instructed to elevate his leg as needed and avoid strenuous activities for 2-3 weeks.

2. Hypertension.
- Medical Treatment: The patient will continue lisinopril 20 mg daily. I have also provided a referral to see a nutritionist for dietary changes.

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


[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] okay so we are recording okay so okay so i understand you've so you've got a past medical history of type two diabetes and you're coming in and for evaluation of a newly diagnosed ovarian cancer so how are you doing today
[patient] i do n't hear the question but i'm assuming that you when you say batcher so when i start talking about my dog and my three cats and all that those sort of things are not going to be included in the in the note
[doctor] right i want you you can talk about those things yes
[patient] okay
[doctor] okay so with your newly diagnosed ovarian cancer so how are you feeling today how are you doing
[patient] i'm doing pretty good depressed
[doctor] little depressed i can understand it's a lot to take on is n't it
[patient] yes
[doctor] okay okay so lem me ask you some questions so what kind of symptoms were you having that prompted you your doctor to do the tests
[patient] i was having severe pain and bleeding
[doctor] okay now do you have other symptoms such as weight loss constipation vomiting or issues with urination
[patient] no vomiting but constipation and weight loss
[doctor] okay yeah that's understandable so do you have any children or have you ever been pregnant
[patient] i'm sorry i did n't hear that part
[doctor] do you have any children or have you ever been pregnant
[patient] no to either one of those
[doctor] okay so and do you know at what age you got your period and when you started menopause
[patient] thirteen for my period and twenty eighth for menopause
[doctor] okay do you take any oral hormone replacement therapy
[patient] no
[doctor] okay any history of endometriosis
[patient] any history of what
[doctor] endometriosis
[patient] no
[doctor] okay how about any family history of any gynecological cancers
[patient] i was adopted
[doctor] okay okay so i'm just gon na do a quick exam of your abdomen and then perform a vaginal exam okay
[patient] okay
[doctor] alright okay so i do feel the mass on the where to go here okay
[patient] i did n't know you're gon na play a doctor today
[doctor] i did okay okay so i do feel the mass on the left side but everything else looks good and on abdominal exam there is slight tenderness to palpation of the left lower quadrant no rebounding or guarding on vaginal exam there are no external lesions on the labia the vaginal vault is within normal limits the cervix is pink without lesions and on bimanual exam i appreciate a left adnexal mass and there is no masses on the right okay so now i reviewed the results of your abdominal ct which show a three centimeter left ovarian mass with an associated local localized lymph node involvement there is no evidence of gross peritoneal or metastatic disease so lem me tell you a little bit about my assessment and plan so for the first problem so i do think this is most likely ovarian cancer looking at your ct scan it looks like stage three a disease based on the lymph node involvement i want to start by sending off some blood tests like a ca-125 and hcg and afp and ldh these are just tests that help me to determine what type of tumor i'm dealing with and then i want you to undergo genetic counseling and testing to see if you have a genetic predisposition for developing ovarian cancer so this stage of ovarian cancer is treated by performing surgery followed by adjunct chemotherapy so this means we'll start chemotherapy after you've recovered from surgery okay so for the surgery i would perform a hysterectomy remove both ovaries and perform a lymph node dissection to remove the involved and involve lymph nodes as well as any other ones i see and i'll also send a sample of any tissue if there anything that looks suspicious at all and we'll be able to tell exactly what stage this is based on the pathology reports i then recommend chemotherapy with cisplatin and taxol and based on how the surgery goes i may want you to receive intraperitoneal intraperitoneal chemo which is done inserting a small tube into your belly for the chemo to go directly into your peritoneum now i know that was a lot sick in do you have any questions or
[patient] am i gon na die
[doctor] well that's a good question so based on what i see at this time i will we believe you have a favorable diagnosis prognosis and you're also still young and healthy which makes your prognosis even better and we do need to see a final pathology report to give you a definitive answer though okay
[patient] alright alright

CHIEF COMPLAINT

New patient evaluation of newly diagnosed ovarian cancer.

FAMILY HISTORY

The patient was adopted and has no knowledge of any family history.

REVIEW OF SYSTEMS

Constitutional: Reports unintentional weight loss
Gastrointestinal: Reports abdominal pain and constipation. Denies vomiting.
Genitourinary: Reports abnormal vaginal bleeding. Denies urinary issues.
Psychiatric: Reports depression

PHYSICAL EXAM

Gastrointestinal
- Examination of Abdomen: There is slight tenderness to palpation of the left lower quadrant. No rebounding or guarding.

Pelvic
- Examination: There are no external lesions on the labia. The vaginal vault is within normal limits. The cervix is pink without lesions. On bimanual exam, I appreciate a left adnexal mass. No masses on the right.

RESULTS

CT scan of the abdomen was reviewed and demonstrated a 3 cm left ovarian mass with associated localized lymph node involvement. There is no evidence of gross peritoneal or metastatic disease.

ASSESSMENT AND PLAN

1. Ovarian cancer.
- Medical Reasoning: Looking at her abdominal CT results, it appears to be stage IIIA disease based on the lymph node involvement.
- Patient Education and Counseling: I explained to the patient that the typical approach to treating this stage of cancer is surgical intervention followed by adjunct chemotherapy. The procedure and subsequent chemotherapy plans were discussed in detail. Given that she is young and otherwise healthy, I reassured her that I believe her prognosis is favorable based on her current status, however, this is dependent on the final pathology report. All of her questions were answered.
- Medical Treatment: I want to start by ordering several blood tests including a CA-125, hCG, AFP, and LDH. I also want her to undergo genetic counseling and testing to see if she has a genetic predisposition for developing ovarian cancer. I recommend we perform a hysterectomy and oophorectomy, as well as a lymph node dissection to remove any involved lymph nodes. Any concerning tissue will be biopsied and sent to pathology for staging. After she has recovered from surgery, she will start chemotherapy treatment with cisplatin and Taxol. We may also consider intraperitoneal chemotherapy.

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


[doctor] alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened
[patient] well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then all of a sudden i'm here
[doctor] hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath
[patient] i did but i did n't think anything of it
[doctor] sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on
[patient] i have but i miss them every year and then so i think today i took one
[doctor] okay alright yeah i have you on bumex cozaar and norvasc does that sound right
[patient] i guess so that sounds about right
[doctor] alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that
[patient] i've just been eating anything honestly i try to watch it here and there but to tell you the truth i'd looks i was eating
[doctor] yeah i i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or
[patient] little bit of everything here and there i do lot of chips
[doctor] sure
[patient] they're pretty good i guess they're salty even though the light salt ones but
[doctor] mm-hmm
[patient] kinda whatever i can get my hands on really
[doctor] okay alright how are you feeling right now
[patient] i'm doing a little okay i guess i'm just out of breath a little bit but it's nothing i ca n't handle
[doctor] sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those
[patient] no i have n't got one yet i know i needed to get one
[doctor] yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately
[patient] just like i said when i was walking outside it helped a little bit but again i just walked it off
[doctor] sure any problems sleeping
[patient] no i sleep like a rock
[doctor] good good to hear have you had any chest pain
[patient] slightly here or there but i thought it was just heartburn
[doctor] sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that
[patient] i've been pretty good on it very once every week maybe just one
[doctor] okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay
[patient] that sounds good document
[doctor] awesome weigh yourself daily do you have a scale at home
[patient] no but i can get one
[doctor] okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good
[patient] that sounds good to me
[doctor] great okay david do you have any other questions
[patient] no other questions at this time just i guess i just need to make sure to take my medication on time that's about it
[doctor] yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well
[patient] i will do my best
[doctor] alright thanks hope you feel better
[patient] thank you

CHIEF COMPLAINT

Follow up.

SOCIAL HISTORY

The patient has been trying to limit his tobacco use for 2 years. He reports smoking once every week.

MEDICATIONS

Bumex 2 mg once daily.
Cozaar 100 mg daily.
Norvasc 5 mg once daily.

REVIEW OF SYSTEMS

Constitutional: Denies problems sleeping.
Cardiovascular: Reports chest pain.
Respiratory: Reports shortness of breath.
Musculoskeletal: Reports bilateral ankle swelling.

VITALS

Blood pressure is 128/72 mm Hg. Other vital signs are within normal limits.

PHYSICAL EXAM

Neck
- General Examination: No JVD

Respiratory
- Auscultation of Lungs: Clear bilaterally.

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

Musculoskeletal
- Examination: Lower extremities show trace edema.

RESULTS

An echocardiogram, obtained at an outside facility, was reviewed today. It demonstrates a preserved ejection fraction of 55%. Normal diastolic filling. Mild to moderate mitral regurgitation.

ASSESSMENT AND PLAN

1. CHF.
- Medical Reasoning: The patient’s recent epsiode resulting in the emergency room visit was likely caused by his dietary indiscretion and uncontrolled hypertension that we have been monitoring.
- Patient Education and Counseling: I reviewed the echocardiogram results with the patient and discussed the importance of following dietary restrictions. I encouraged the patient to take his medication on a consistent basis. I advised him to purchase a scale to weigh himself daily.
- Medical Treatment: He will continue Bumex 2 mg once daily. He was provided with a referral to a nutritionist in consultation for further assistance with his dietary requirements to lower his sodium intake.

2. Hypertension.
- Medical Reasoning: This is currently uncontrolled.
- Patient Education and Counseling: I explained the importance of taking his medication on a daily basis. I encouraged the patient to purchase a blood pressure cuff and track his blood pressures.
- Medical Treatment: He will continue Cozaar 100 mg daily as well as the Norvasc 5 mg once daily. I will order a renal artery ultrasound for further evaluation.

3. Systolic ejection murmur.
- Medical Reasoning. Stable.

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

INSTRUCTIONS

The patient was instructed to call me if he gains 3 pounds in 2 days.