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

CHIEF COMPLAINT

Left knee pain.

HISTORY OF PRESENT ILLNESS

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

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

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

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

MEDICAL HISTORY

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

SOCIAL HISTORY

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

MEDICATIONS

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

REVIEW OF SYSTEMS

Musculoskeletal: Reports left knee pain and instability,

VITALS

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

PHYSICAL EXAM

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

RESULTS

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

ASSESSMENT

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

PLAN

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

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

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


[doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three nonsmile 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 cisplestan as well as the eupside 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 cisplacin and the etoside and we're gon na continue with your current dose of radiation at forty five grade 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] alright
[patient] you're ready just
[doctor] ready
[patient] hi kyle how are you today
[doctor] i'm doing well i'm just anxious about my pcp told me that i had some abnormal lab work and why she wanted me to be seen by you today
[patient] yeah i bet that did make you nervous i i see that she referred you for a low immunoglobulin a level is that your understanding
[doctor] yeah i mean i do n't even really understand what that means but yeah that's what she told me
[patient] yeah that's a mouthful
[doctor] yeah
[patient] it it's the the one of the antibodies in your body and that that really makes that your body makes to fight infections it's a little bit low i'm happy to explain it a little bit more to you i just have a few more questions okay so let's start again here
[doctor] i'll do this
[patient] i i think i would break that
[doctor] yeah i just saw that
[patient] if you can do that
[doctor] okay
[patient] yeah so we'll we'll just
[doctor] okay
[patient] you can leave it the way it is for now i just i think break that up
[doctor] okay alright so yeah that sounds fine for me
[patient] yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections
[doctor] yeah yeah i had a recent physical and she did this as part of her my physical i do tend to get infections but i do n't know i i'm so used to it so i do n't know if this is more than usual in the wintertime i get a lot of colds and they do seem to i always say that my colds kind of linger for a long time but i do n't know if it's more than usual
[patient] okay how about any abdominal infections
[doctor] diarrhea no
[patient] frequently
[doctor] no not that i can not that i say can think of
[patient] okay what about your family are are anyone in your family that you know have immune deficiencies
[doctor] no my family is actually pretty healthy
[patient] okay and how about do you have any other medical conditions
[doctor] yeah my pcp just started me on metformin i just got diagnosed with type two diabetes
[patient] okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street
[doctor] yes and that's probably part of the cause of my diabetes yes
[patient] yeah well i guess you're gon na have to watch that
[doctor] i know i know
[patient] but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away
[doctor] right
[patient] but have you ever needed to receive a blood transfusion or blood products
[doctor] no i actually tried to give blood but they i did n't qualify because i had recently traveled internationally
[patient] okay where did you go
[doctor] i was in zambia
[patient] hmmm i heard that's beautiful
[doctor] it's so beautiful it's so beautiful i had a great time
[patient] okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial
[doctor] no
[patient] no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about the assessment and plan so for your first problem the that a iga deficiency is it very common immunodeficiency your your body makes many different types of antibodies in one of your z iga is just a little bit lower than normal now most of the time people live their entire life without even knowing they have that deficiency and function perfectly normal now some people may find that they get tend to get frequent respiratory tract or sinus or abdominal infections but this does n't necessarily seem to be the case for you now it can go along with other immunodeficiencies but i think there is a low likelihood hood in your case but we're gon na order some additional blood work that includes checking those other antibodies now do you have any questions on what i just told you
[doctor] yeah so is there anything i need to do or should be watching for or should i be worried
[patient] no i i really do n't think you need to be worried now we're gon na check these additional studies and that will give us some more guidance but really i think this is just a finding that's common to you and you know it it's many people have have have these type of you know immunodeficiency what i want you to watch for is those infections that do n't stop you have trouble getting it under control or you know any changes to your abdominal tract you know severe diarrhea
[doctor] anything like that then you know we may want to look at it a little bit further but for now i do n't think there is anything significant we want to do now go ahead and get your lab work and
[patient] bring you in for that now the only other thing that i would say is if you eat end up needing any blood products between now and when i see you next make sure you tell them that you have that iga deficiency
[doctor] why is that
[patient] well there is a risk that your body can strongly react to some blood products and they just need to know that so they're prepared so anytime you get blood just make sure you say that you have a history of a an an iga deficiency
[doctor] okay okay thank you
[patient] you're welcome
[doctor] okay

HISTORY OF PRESENT ILLNESS

Kyle Lee is a pleasant 46-year-old male who presents to the clinic today for evaluation of low immunoglobulin A level. He was referred to our offices by his primary care physician after routine labs revealed abnormalities. The patient states he has been experiencing frequent infections. During the winter months, he experiences frequent colds that tend to linger, however this is not uncommon for him. The patient denies abdominal issues or diarrhea.

The patient was recently diagnosed with type 2 diabetes. He is currently taking metformin.

MEDICAL HISTORY

Patient denies a history of blood transfusions.

SOCIAL HISTORY

He recently traveled internationally on a trip to Zambia. His family owns a local doughnut shop.

FAMILY HISTORY

Patient denies a family history of immune deficiencies.

REVIEW OF SYSTEMS

Gastrointestinal: Denies abdominal issues or diarrhea.

VITALS

Temperature: Normal.
All other vitals were reviewed and are within normal limits.

PHYSICAL EXAM

NECK: No swelling noted. No lymphadenopathy.
CV: Normal heart rhythm with no murmurs.
RESPIRATORY: Lungs are clear. There's no wheezes, rales, or rhonchi.
Gastrointestinal: Abdomen is soft and without tenderness.

RESULTS

I did review the results of her recent lab work. It is consistent as her primary care physician noted with an IgA deficiency.

ASSESSMENT

IgA deficiency.

PLAN

After reviewing the patient's examination today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that the results of his recent lab work is consistent with an IgA deficiency. I have recommended that we obtain additional blood work to check his other antibodies. I encouraged the patient to be aware of lingering infections or abdominal changes including diarrhea. If he experiences these issues, he should report them to my office so we may investigate further, however I do not believe there is a need for that at this time. In the meantime, he should report this IgA deficiency in the event that he needs any blood transfusions. Questions were invited and answered today.


[doctor] hey lawrence how're you doing
[patient] i'm doing alright aside from this elbow pain
[doctor] so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain
[patient] so i really during this pandemic i really got into ceramics and doing pottery so i've been doing a lot of pottery and over the past week i then started to develop this elbow pain
[doctor] okay and then so tell me a little bit more about that elbow pain where does it hurt exactly
[patient] you know it hurts a lot in the inside of my elbow
[doctor] okay so the inside of your right elbow okay
[patient] yeah
[doctor] and then does the pain radiate down your arm or up into your shoulder or anything like that
[patient] it does n't go into my shoulder it's it stays mostly at my elbow but it can go down a bit into my forearm
[doctor] okay and then do you remember any trauma did you hit your arm or elbow or any on anything
[patient] no nothing i i really was trying to think if there is anything else and i ca n't think of anything
[doctor] okay and you've never injured that right elbow before
[patient] no
[doctor] alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life
[patient] i would say probably a six
[doctor] okay and does that pain keep you up at night
[patient] it does
[doctor] okay and when you have that kind of pain does it keep you from doing other type of activities
[patient] yeah i mean i still try to like work through with using my arm but yeah it's it's it's difficult for me sometimes to lift and do things because of that pain
[doctor] okay and then and how long has this pain been going on
[patient] about four days now
[doctor] alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief
[patient] i've tried ibuprofen that helps a little but not much
[doctor] okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here
[patient] yes i do
[doctor] okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that
[patient] not really
[doctor] okay now turn your wrist in so do you have any pain when you do that
[patient] yeah that hurts
[doctor] okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist
[patient] yes i do
[doctor] alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend
[doctor] that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay
[patient] alrighty
[doctor] alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week
[patient] alright thank you
[doctor] thank you

CHIEF COMPLAINT

Right elbow pain.

HISTORY OF PRESENT ILLNESS

Lawrence Butler is a pleasant 45-year-old male who presents to the clinic today for the evaluation of right elbow pain.

Over the past week, the patient has developed 6/10 pain in the "inside" of his right elbow. The pain may radiate into his forearm on occasion, but does not extend up to his shoulder. He denies any history of trauma or injury, but he did start making pottery during the COVID-19 pandemic and suspects that his symptoms could be related to that. His symptoms affect his ability to lift objects or perform his typical activities of daily living. Ibuprofen provides minimal symptomatic relief.

SOCIAL HISTORY

The patient reports that he began making pottery during the COVID-19 pandemic.

MEDICATIONS

The patient reports that he has been taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right elbow pain.

VITALS

Normal

PHYSICAL EXAM

MSK: Examination of the right elbow: Moderate tenderness at the medial epicondyle. No pain with supination of the forearm. Pain with pronation of the forearm. Pain with resistance against flexion of the wrist.

RESULTS

X-ray imaging of the right elbow was obtained and reviewed in office today. These reveal no evidence of fracture or bony abnormality.

ASSESSMENT

Right medial epicondylitis.

PLAN

The patient and I discussed his diagnosis in detail, and I explained that his symptoms are likely caused by overuse and potential damage of the tendons. We will provide him with sling to be worn during the day while he is awake. I want him to take ibuprofen 600 mg every 6 hours with food for a full week and ice the elbow for 20 minutes, 3 times daily. Finally, I advised the patient to rest his elbow and avoid doing any pottery for the next couple of weeks.

INSTRUCTIONS

The patient will follow up in 1 week.


[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.


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

CHIEF COMPLAINT

Tick bite.

MEDICAL HISTORY

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

SOCIAL HISTORY

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

MEDICATIONS

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

REVIEW OF SYSTEMS

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

VITALS

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

PHYSICAL EXAM

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

Respiratory
- Auscultation of Lungs: Clear bilaterally.

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

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

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

RESULTS

Patient's previous kidney function is within normal limits.

ASSESSMENT AND PLAN

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

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

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

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


[doctor] hi , andrew . how are you ?
[patient] hey , good to see you .
[doctor] i'm doing well , i'm doing well .
[patient] good .
[doctor] so , i know the nurse told you about dax . i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] uh , so , andrew is a 59-year-old male with a past medical history , significant for depression , type two diabetes , and hypertension who presents today with an upper respiratory infection . so , andrew , what's going on ?
[patient] yeah . we were doing a bit of work out in the yard in the last week or so and i started to feel really tired , was short of breath . um , we- we're not wearing masks as much at the end of the summer and i think i caught my first cold and i think it just got worse .
[doctor] okay . all right . um , now , have you had your covid vaccines ?
[patient] yeah , both .
[doctor] okay . all right . and , um , do you have any history of any seasonal allergies at all ?
[patient] none whatsoever .
[doctor] okay . all right . and when you say you're having some shortness of breath , did you feel short of breath walking around or at rest ?
[patient] uh , usually , it was lifting or carrying something . we were doing some landscaping , so i was carrying some heavy bags of soil and i , i got really winded . it really surprised me .
[doctor] okay . and are you coughing up anything ?
[patient] not yet , but i feel like that's next .
[doctor] okay . and fevers ?
[patient] uh , i felt a little warm , but i , i just thought it was because i was exerting myself .
[doctor] okay . all right . and any other symptoms like muscle aches , joint pain , fatigue ?
[patient] my elbows hurt quite a bit and my knees were pretty tired . l- like i said , i really felt some tension around my knees , but , uh , i think that was a lot to do with , uh , lifting the bags .
[doctor] okay . all right . um , so , you know , how about , how are you doing in terms of your other medical problems , like your depression ? how are you doing with that ? i know we've , you know , talked about not putting you on medication for it because you're on medication for other things . what's going on ?
[patient] i- it's been kind of a crazy year and a half . i was a little concerned about that but , for the most part , i've been , been doing well with it . my , my wife got me into barre classes , to help me relax and i think it's working .
[doctor] okay . all right , great . and , and in terms of your diabetes , how are you doing watching your , your diet and your sugar intake ?
[patient] uh , i've been monitoring my sugar levels while i am going to work during the week . uh , not so , uh , if its saturday or sunday i usually don't remember . uh , the diet's been pretty good for the most part , except for , you know , some house parties and things like that . but , uh , been good for the most part .
[doctor] okay and have they been elevated at all since this episode of your-
[patient] no .
[doctor] okay . and then , how , lastly , for your high blood pressure , have you been monitoring your blood pressures at home ? did you buy the cuff like i suggested ?
[patient] uh , same thing . during the while i'm going to work, i'm regular about monitoring it, but if its a saturday or sunday, not so much . but , uh , it's , it's been under control .
[doctor] but you're taking your medication ?
[patient] yes .
[doctor] okay . all right . well , you know , i know that , you know , you've endorsed , you know , the shortness of breath and some joint pain . um , how about any other symptoms ? nausea or vomiting ? diarrhea ?
[patient] no .
[doctor] anything like that ?
[patient] no .
[doctor] okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , Sarah , show me the vital signs . so , your vital signs here in the office look quite good .
[patient] mm-hmm .
[doctor] you know , everything's looking normal , you do n't have a fever , which is really good . um , i'm just gon na go ahead and listen to your heart and your lungs and , kind of , i'll let you know what i hear , okay ?
[patient] sure .
[doctor] okay . so , on your physical exam , you know , your heart sounds nice and strong . your lungs , you do have scattered ronchi bilaterally on your lung exam . uh , it clears with cough . um , i do notice a little bit of , um , some edema of your lower extremities and you do have some pain to palpation of your elbows bilaterally . um , so , let's go ahead , i want to look at some of your results , okay ?
[patient] mm-hmm .
[doctor] hey , Sarah . show me the chest x-ray .
[doctor] so , i reviewed the results of your chest x-ray and everything looks good . there's no airspace disease , there's no pneumonia , so that's all very , very good , okay ?
[patient] good .
[doctor] hey , Sarah . show me the diabetic labs .
[doctor] and here , looking at your diabetic labs , you know , your hemoglobin a1c is a little elevated at eight .
[patient] mm-hmm .
[doctor] i'd like to see that a little bit better , around six or seven , if possible .
[patient] mm-hmm .
[doctor] um , so let's talk a little bit about my assessment and my plan for you .
[patient] mm-hmm .
[doctor] so , for your first problem , this upper respiratory infection , i believe you , you have a viral syndrome , okay ? we'll go ahead and we'll send a covid test , just to make sure that you do n't have covid .
[patient] mm-hmm .
[doctor] uh , but overall , i think that , um , you know , this will resolve in a couple of days . i do n't think you have covid , you do n't have any exposures , that type of thing .
[patient] mm-hmm .
[doctor] so , i think that this will improve . i'll give you some robitussin for your cough and i would encourage you take some ibuprofen , tylenol for any fever , okay ?
[patient] you got it .
[doctor] for your next problem , your depression , you know , it sounds like you're doing well with that , but again , i'm happy to start on a med- , a medical regiment or ...
[patient] mm-hmm .
[doctor] . refer you to psychotherapy , if you think that that would be helpful .
[patient] mm-hmm .
[doctor] would you like that ?
[patient] u- u- um , maybe not necessarily . maybe in a , uh , few months we'll check on that .
[doctor] okay . all right .
[doctor] for your third problem , your type two diabetes , i want to go ahead and increase your metformin to 1000 milligrams , twice daily .
[patient] mm-hmm .
[doctor] and i'm gon na get an- another hemoglobin a1c in four months , okay ?
[patient] okay , sure .
[doctor] hey , Sarah . order a hemoglobin a1c .
[doctor] and lastly , for your high blood pressure , it looks like you're doing a really good job managing that . i want to go ahead and continue you on the , um , lisinopril , 20 milligrams a day .
[patient] mm-hmm .
[doctor] and i'm gon na go ahead and order a lipid panel , okay ?
[patient] sure .
[doctor] do you need a refill of the lisinopril ?
[patient] actually , i do .
[doctor] okay . hey , Sarah . order lisinopril , 20 milligrams daily .
[doctor] so , the nurse will be in , she'll help you , uh , make a follow-up appointment with me . i want to see you again in about four months .
[patient] okay .
[doctor] let me know if your symptoms worsen and we can talk more about it , okay ?
[patient] you got it .
[doctor] all right . hey , Sarah . finalize the note .

CHIEF COMPLAINT

Upper respiratory infection.

HISTORY OF PRESENT ILLNESS

Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.

The patient reports that he has been doing a bit of work out in the yard in the last week or so. He started to feel really tired and short of breath. The patient denies coughing up anything, but he feels like he will soon be coughing up phlegm. He denies having a fever, but he felt a little warm. He attributed this to exerting himself. He reports that his elbows hurt quite a bit. He notes his knees were pretty tired and he felt some tension around his knees. The patient attributes these symptoms to lifting heavy bags. He has not been wearing a mask as much recently. He believes that he caught his first cold and his symptoms have worsened. He has had both of his COVID vaccinations.

He denies any history of seasonal allergies.

Regarding his depression, he states it has been a crazy year and a half. He was a little concerned about that, but for the most part, he has been doing well with it. His wife got him into barre classes and this has been relaxing.

Regarding his diabetes, he has been monitoring his sugar levels while he is at work, but is not as consistent on Saturdays and Sundays. His diet has been pretty good for the most part, except for some house parties. They have not been elevated since his respiratory symptoms began.

The patient has been monitoring his blood pressure at home. He reports that he is very regular with monitoring his blood pressure during the week, though less consistently on weekends. He reports his blood pressure has been under control. He has continued to utilize lisinopril 20 mg, daily.

The patient denies nausea, vomiting, diarrhea.

REVIEW OF SYSTEMS

• Constitutional: Denies fever.
• Cardiovascular: Endorses dyspnea on exertion.
• Respiratory: Endorses shortness of breath and cough.
• Gastrointestinal: Denies nausea or diarrhea.
• Musculoskeletal: Endorses bilateral elbow and knee pain.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Respiratory: Scattered rhonchi bilaterally, clears with cough.
• Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds.
• Musculoskeletal: Edema in the bilateral lower extremities. Pain to palpation of the bilateral elbows.

RESULTS

X-ray of the chest is unremarkable. No airspace disease. No signs of pneumonia.

Hemoglobin A1c is elevated at 8.

ASSESSMENT AND PLAN

Andrew Campbell is a 59-year-old male with a past medical history significant for depression, type 2 diabetes, and hypertension. He presents today with an upper respiratory infection.

Upper respiratory infection.
• Medical Reasoning: I believe he has contracted a viral syndrome. His chest x-ray was unremarkable and he has received both doses of the COVID-19 vaccination.
• Additional Testing: We will obtain a COVID-19 test to rule this out.
• Medical Treatment: I recommend he use Robitussin for cough, as well as ibuprofen or Tylenol if he develops a fever.

Depression.
• Medical Reasoning: He has been practicing barre classes and is doing well overall.
• Medical Treatment: I offered medication or psychotherapy, but the patient opted to defer at this time.

Diabetes type 2.
• Medical Reasoning: His blood glucose levels have been well controlled based on home monitoring, but his recent hemoglobin A1c was elevated.
• Additional Testing: We will repeat a hemoglobin A1c in 4 months.
• Medical Treatment: We will increase his metformin to 1000 mg twice daily.

Hypertension.
• Medical Reasoning: He has been compliant with lisinopril and his blood pressures have been well controlled based on home monitoring.
• Additional Testing: We will order a lipid panel.
• Medical Treatment: He will continue on lisinopril 20 mg once daily. This was refilled today.

Follow up: I would like to see him back in approximately 4 months.

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


[doctor] hi andrea , how are you ?
[patient] i'm doing well . how are you ?
[doctor] doing well . uh , so i know the nurse told you about dax . i'd like to tell dax a little bit about you . okay ?
[patient] okay .
[doctor] so , andrea is a 52-year-old female with a past medical history significant for rheumatoid arthritis , atrial fibrillation , and reflux who presents today for her annual exam . so andrea , it's been a year since i saw you . how are you doing ?
[patient] i'm doing well . so , i've been walking like you told me to and , um , exercising and doing yoga , and that's actually helped with my arthritis a lot , just the- the constant movement . so , i have n't had any joint pain recently .
[doctor] okay . good . so , no- no issues with any stiffness or pain or flare ups over the last year ?
[patient] no .
[doctor] okay . and i know that we have you on the methotrexate , are you still taking that once a week ?
[patient] yes , i am .
[doctor] okay . and any issues with that ?
[patient] no .
[doctor] no . okay . and then in terms of your a-fib , how are you doing with that ? are you having any palpitations ? or , i know that you've kind of been in and out of it over the past , you know , year or so .
[patient] yeah . i've still been having palpitations . the- the last one i had was about a week ago . i've noticed that when i start to get stressed , um , they start to flare up again . so , i've been trying meditation , trying running with my dog to try and relieve the stress but it has n't really been working .
[doctor] yeah . i- i know that you had called , um , last month and we- we did that event monitor for you , uh , which we'll take a look at in a few minutes . okay ?
[patient] okay .
[doctor] um , how about um , your reflux ? you know , we had placed you on the protonix , uh , has that helped ? and i know that you were gon na do some dietary modifications .
[patient] yeah . i cut out soda and that- that's helped- seemed to help , and the medication's been helping too . i have n't had a flare up in over , i think , five months .
[doctor] okay . all right . um , so , you know , i know that you did the review of systems sheet when you checked in and , you know , you had- you know , you endorsed the palpitations and you had some nasal congestion . any other symptoms ? you know , chest pain , shortness of breath , nausea or vomiting ?
[patient] no , nothing like that . just the nasal- nasal congestion because of my allergies .
[doctor] okay . all right . okay . well , i'd like to go ahead and do a quick physical exam , okay ?
[patient] okay .
[doctor] all right . hey Sarah , show me the vital signs . okay . so , you're in- here in the office today , it looks like , you know , your heart rate's really good today . it's- it's nice and controlled so that's good . um , i'm just gon na take a look into your heart and lungs and- and i'll let you know what i find . okay ?
[patient] okay .
[doctor] okay . so , on physical examination , um , you know , everything looks really good . on your heart examination , i do appreciate a slight 2/6 systolic- systolic ejection murmur , um , which we've heard in the past so i'm not worried at that . you're in the- a nice regular rate and rhythm at this time . your lungs are nice and clear . on your right elbow , i do notice some edema and some erythema . does it hurt when i press it ?
[patient] yeah , it does a bit .
[doctor] okay . so , she has pain to palpation of the right elbow . um , and you have no lower extremity edema , okay ? um , so i wan na go ahead and just take a look at some of your results . okay ?
[patient] okay .
[doctor] hey Sarah , show me the event- event monitor results . okay . so , you know , this is the results of your event monitor which shows that , you know , you're in and out of a-fib , you have what we call a conversion pause . you know , you're in a-fib , you pause , and then you go back to regular rhythm . so , we'll talk about that , okay ?
[patient] okay .
[doctor] hey Sarah , show me the autoimmune panel . so , looking here at your autoimmune panel , everything looks good , it looks like you're- you know , everything is well controlled with your rheumatoid arthritis on the methotrexate . okay ? so , let me just go over a little bit about my assessment and my plan for you . okay ?
[patient] okay .
[doctor] so for your first problem , your rheumatoid arthritis , again , everything looks good . i wan na just continue you on the methotrexate 2.5 mg , once weekly . um , and uh , if you need a referral back to see the rheumatologist , let me know , but i think everything seems stable now . do you need a refill of the methotrexate ?
[patient] yes , i do .
[doctor] okay . hey Sarah , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ?
[patient] okay .
[doctor] hey Sarah , order a referral to cardiology . and for your last problem , the reflux , you know , i wanna- i want you to just continue on the protonix , 40 mg a day . continue with your dietary modifications , you know , avoiding coffee and spicy foods , that type of thing . okay ? and then let me know if you have any other issues with that , okay ?
[patient] will do .
[doctor] any questions ?
[patient] no , i do n't .
[doctor] okay . all right . it was good to see you .
[patient] good seeing you .
[doctor] hey Sarah , finalize the note .

CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.

The patient states she is doing well. She has been walking, exercising, and doing yoga, which has helped with her arthritis. She denies issues with stiffness, pain, or flare ups over the last year. The patient has continued utilizing methotrexate 2.5 mg once a week and denies issues with that.

In terms of her atrial fibrillation, she endorses continued palpitations. The last episode she had was about 1 week ago. She has noticed that when she starts to get stressed they start to flare up again. She has tried meditation and running with her dog for stress relief, however these have not been helpful. The patient had called last month and had an event monitor done.

Regarding her GERD, she has continued to utilize Protonix 40 mg a day. The patient has cut out soda, which seemed to help. She has not had a flare up in over 5 months.

The patient endorses nasal congestion because of her allergies. She denies chest pain, shortness of breath, nausea, and vomitting.

REVIEW OF SYSTEMS

• Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies.
• Cardiovascular: Denies chest pain or dyspnea. Endorses palpitations.
• Respiratory: Denies shortness of breath.
• Musculoskeletal: Denies joint pain.

PHYSICAL EXAMINATION

• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. Slight 2/6 systolic ejection murmur.
• Musculoskeletal: No lower extremity edema. Edema and erythema of the right elbow. Pain to palpation of the right elbow.

RESULTS

Event monitor: Positive for conversion pause.

Autoimmune panel: Normal. Well controlled rheumatoid arthritis.

ASSESSMENT AND PLAN

Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.

Rheumatoid arthritis.
• Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal.
• Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today.
• Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know.

Atrial fibrillation.
• Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause.
• Specialist Referrals: We will refer her to cardiology for a cardiac ablation.

GERD.
• Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months.
• Medical Treatment: Continue on Protonix 40 mg daily.
• Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers.

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