[doctor] hi janet , how are you ?
[patient] good , how are you ?
[doctor] i'm good . uh , are you ready to get started ?
[patient] yes .
[doctor] okay . so , janet is a 33-year-old female , here for some , some joint paint . what , what joint's been bothering you , janet ?
[patient] it's been mostly , um , my knees , actually . i've been doing more stair type workouts , which i thought was , you know , building muscle , uh , on my knees and supposed to help .
[doctor] mm-hmm .
[patient] but in turn it , it really has n't , so my knees have been really bothering me .
[doctor] okay . all right . and is it one knee versus the other ? or both equally ?
[patient] it's both equally .
[doctor] okay . and have you been having any other joint pain like , elbows or shoulder , or anything like that ?
[patient] no , but i , i should mention that like , i had a rotator cuff repair about two years ago .
[doctor] mm-hmm .
[patient] um , but i have n't had any problems since that point .
[doctor] okay , and what shoulder was that ?
[patient] that was my right shoulder .
[doctor] okay , all right . and , um , any pins and needles in your feet at all ? any swelling in your legs ?
[patient] uh , no , nothing like that .
[doctor] okay .
[patient] um , but it would be something though i look out for often , just because i have diabetes .
[doctor] okay , and your blood sugars have been under control ?
[patient] yes , they have been .
[doctor] okay . and have you had any fever or chills ?
[patient] no , nothing like that .
[doctor] okay . any nausea or vomiting , chest pains , shortness of breath ?
[patient] no , but i do have high blood pressure , um , but i , i monitor that and i've been taking medication for that , and that has n't elevated , um , in any way since the joint pain .
[doctor] okay . all right . so , yeah , i see on here that you do take norvasc , five mg a day and you've been taking that every day-
[patient] yes .
[doctor] okay . um , and , um , so let's go ahead and do a quick physical exam on you . so , hey Sarah , show me the blood pressure . your blood pressure's actually pretty high today , so you might be a little nervous here , which is not uncommon .
[patient] yeah .
[doctor] um , so , looking at you , your , your neck is nice and soft , there's no enlarged thyroid . your heart has a regular rate and rhythm . your lungs are clear . your abdomen is nice and soft , but looking at your knees , on your left knee you do have a slight erythema and edema . there is a small efusion present over your left knee . um , you have some decrease flexion and extension of your knee , but your strength in your lower extremities is good . uh , so let's go ahead and look at some of your results . i know that we did some x-rays when you came in .
[patient] yeah .
[doctor] hey Sarah , show me the left knee x-ray . okay , so looking at this , this is an , this is a normal x-ray of your left knee , so you may just have a little bit of a strain going on in your , in your knees there .
[patient] okay .
[doctor] uh , let's look at some of your labs , 'cause i know that you have the diabetes . hey Sarah , show me the labs . so , here your white blood cell count is not elevated , so i'm not concerned about an infection or anything like that . um , hey Sarah , show me the diabetes' labs . okay and , and your a1c is a little elevated , but it's not , it's not terrible , so i think for right now we'll just continue you on the current regimen . um , so my plan from you , for you in terms of the joint pain , um , i'd like to go ahead and , you know , we'll just send some autoimmune labs to work , work up your left knee pain and , uh , we'll work for you to do some physical therapy and i'd like to go ahead and give you anti-inflammatory medication to help with the pain . does that sound okay ?
[patient] that sounds great .
[doctor] okay . hey Sarah , order meloxicam 15 mg once a day . hey Sarah , order a physical therapy referral . hey Sarah , order an autoimmune profile . and then from a hypertension standpoint you , because your blood pressure is a little elevated today , i'd like you to continue to monitor it at home and , you know , send me a report in the next couple of weeks sh- , you know , giving me the , the blood pressure reportings . do you have a blood pressure cuff at home ?
[patient] yes , i do .
[doctor] okay . and then , um , we'll go ahead and order a lipid profile for you . hey Sarah , order a lipid profile . and then for , from a diabetes standpoint let's go ahead and , uh , continue you on your metformin 500 mg twice a day . okay ?
[patient] okay .
[doctor] do you have any questions ?
[patient] no , that's it .
[doctor] okay . the nurse will be in soon . it was good to see you .
[patient] nice seeing you too .
[doctor] hey Sarah , finalize the note .

CHIEF COMPLAINT

Joint pain.

HISTORY OF PRESENT ILLNESS

Ms. Janet Sullivan is a 33-year-old female who presents to the clinic today for evaluation of joint pain.

She localizes the joint pain to her bilateral knees. The patient reports she has been doing stair workouts, which she thought was building muscle on her knees. She denies any pins and needles in her feet or swelling in her legs. The patient notes that she would look out for those symptoms because she has diabetes. She denies any fever or chills. She denies any nausea or vomiting. The patient denies any chest pain or shortness of breath.

She notes she had a right shoulder rotator cuff repair about 2 years ago, but she has not had any problems since that point.

She reports that her diabetes are well-controlled.

The patient does have high blood pressure but she monitors it and takes Norvasc 5 mg a day. She notes her blood pressure has not been elevated since her joint pain started.

REVIEW OF SYSTEMS

• Constitutional: Negative for fever, chills
• Cardiovascular: Negative for chest pain or lower leg swelling.
• Respiratory: Negative for shortness of breath.
• Gastrointestinal: Negative for nausea, vomiting.
• Musculoskeletal: Positive for Arthralgias

PHYSICAL EXAMINATION

Neck
• General Examination: Neck is supple without thyromegaly.

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

Cardiovascular
• Auscultation of Heart: Regular rate and rhythm.

Musculoskeletal
• Left knee: Slight erythema and edema. Small effusion present. Decreased flexion and extension. Strength in lower extremities is good.

RESULTS

Views: Four views left knee.
Indication: Knee pain.
Interpretation: There are no fractures, dislocations, or other abnormalities.

PLAN

Ms. Janet Sullivan is a 33-year-old female who presents to the clinic today for evaluation of joint pain.

Left knee strain.
• Medical Treatment: We will order an autoimmune panel for further workup. I am going to refer her to physical therapy and prescribe meloxicam 15 mg once daily to help with pain.
• Specialist Referrals: Physical therapy.

Hypertension.
• Medical Reasoning: Her blood pressure is elevated in office today, but has been well-controlled on Norvasc 5 mg daily based on home monitoring.
• Medical Treatment: Continue current regimen and home monitoring. She will send me a report in the next couple of weeks. We will also order a lipid profile.

Diabetes type II.
• Medical Reasoning: Her hemoglobin a1C is slightly elevated, but her blood glucose levels have been well-controlled.
• Medical Treatment: Continue metformin 500 mg twice a day.

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


[doctor] morning christine , nice to see you .
[patient] nice to see you too .
[doctor] so i know my nurse told you a little bit of- ... um , about dax and i'm gon na tell dax a little bit about you , if that's okay ?
[patient] go for it .
[doctor] okay , great . um , uh , this is christine . she's a 63-year-old female patient . you're here for your routine , um , yearly exam . um , i know you have a history of high blood pressure and you've had some depression in the past . and i also know you did have a carpal tunnel release done about two years ago . um , how have you been doing ?
[patient] i've been doing well . um , the depression standpoint is doing great . i've been using , um , the medication you prescribed me last time and going to therapy every week . and that's really helped me manage .
[doctor] okay . and you're sleeping well at night ? and everything's been going well from that standpoint ?
[patient] yeah , i've been getting a full eight hours .
[doctor] okay . and no thoughts of hurting yourself or anything like that ?
[patient] no .
[doctor] okay , good . um , and , um , i- i know you've had some high blood pressure in the past . have you been checking your blood pressure ?
[patient] i have . it's been a little bit up and down-
[doctor] okay .
[patient] lately , i have n't had a normal , um , normal reading- reading in a couple of weeks . um , it's either been high or low . um , has n't really stayed put .
[doctor] has n't really stayed put ?
[patient] yeah .
[doctor] okay . and , um , you've been talking your medication though , right ?
[patient] yes , i have .
[doctor] okay .
[patient] my diet's been a little all over the place . i have been really stressed with work and putting in more hours, so you know, it has been hard. i have not had time to go to the grocery store, let alone prepare and cook meals. so, i have been eating a lot of frozen meals.
[doctor] okay .
[patient] that type of thing .
[doctor] and have you had any headaches or swelling or anything like that that's been abnormal ?
[patient] i have some headaches but i just thought that was looking at a computer screen all day .
[doctor] okay , well , that's fair .
[patient] yeah , exactly .
[doctor] okay good . and , um ... i know my nurse did a review of systems . other than what we've just talked about , has there been anything else that you wanted to add to that ?
[patient] um , my carpal tunnel release has been doing well . on , uh , we did that , i think it was two years ago now .
[doctor] okay .
[patient] uh , on my right , um , wrist , and that's been great .
[doctor] great , great . no numbness or tingling in your hands ?
[patient] no .
[doctor] fingers ? okay , good . all right , well , um , lem me do a quick exam if that's okay ?
[patient] okay .
[doctor] deep breath . squeeze my fingers for me . feel me touch you here ?
[patient] yup .
[doctor] can you touch down here ?
[patient] mm-hmm .
[doctor] can you push your leg out ? push this one up . pull it back . yeah , good . okay . so on my exam , um ... your exam's essentially normal , your lungs are clear , are- ... you do n't have any adenopathy in your neck , you do n't have any , um , uh , hyperthyroidism . um , your heart is regular without any murmurs . um , your grips are equal , neurologically intact , strength is good , pulses are good . so overall , um , your exam is fine . let's take a- a look at some of your labs and vital signs .
[patient] okay .
[doctor] hey Sarah , show me the blood pressure . okay , so here in the office today it is a little bit elevated , okay ? so your blood pressure is a little bit high . so the results , um , do show that . um , hey Sarah , show me the labs . okay , so good news is is your- your labs are all essentially normal , so the results of your labs are essentially normal , okay ? so ... um , my assessment is that your- ... you do have hypertension still . um , and i think we need to increase your blood pressure medicine a little bit , okay ? so i'm gon na increase your lisinopril to 10 milligrams a day , just once a day , um , but i'm gon na increase that a little bit , okay ? and then want you to check it and i'm gon na have you come back in a month and we'll see how you're doing with regards to that , okay ?
[patient] okay .
[doctor] um , your second problem is your dep- depression , you're doing great , i do n't wan na change anything at this point . let's just stay- ... we'll change one thing with your high blood pressure-
[patient] mm-hmm .
[doctor] so i do n't wan na change any other medications at this point in time , so let's just leave that as it is .
[patient] okay .
[doctor] and then your third problem was your carpal tunnel . that seems to be doing well . if you notice any tingling or any changes or you get some of those symptoms back , just let me know . okay ?
[patient] okay .
[doctor] all right . anything else i can do for you today ?
[patient] no , that's it .
[doctor] okay . great . uh , lem me get you checked out .
[patient] okay .
[doctor] hey Sarah , finalize the report .

CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

Christine Flores is a 63-year-old female presenting for her yearly exam. She has a history of high blood pressure and depression in the past. She also had a right carpal tunnel release done about 2 years ago.

The patient states that she has been doing well with her depression. She notes that she has been taking her medication as prescribed at her last visit. She states that she has been going to therapy every week, which has helped her manage her symptoms. The patient notes that she is sleeping well at night and has been getting a full 8 hours. She denies any thoughts of self-harm or harming others.

The patient states that she has been checking her blood pressure at home. She notes that her blood pressure has fluctuated lately. She states that she has not had a normal reading in a couple of weeks. The patient has continued utilizing her medications.

She states that her diet has been a little all over the place. The patient notes that she has been working more hours. She reports that she has had some headaches, however, she thought that it was related to her increased screen time.

The patient states that her right carpal tunnel release has been doing well. She denies numbness or tingling in her hands or fingers.

REVIEW OF SYSTEMS

• Cardiovascular: Endorses blood pressure issues.
• Neurological: Endorses headaches.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Neurological/Psychological: Appropriate mood and affect. Bilateral grip strength equal. Neurologically intact.
• Neck: Supple without thyromegaly or cervical lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.

VITALS REVIEWED

• Blood Pressure: Elevated.

RESULTS

Laboratory studies are all within normal limits.

ASSESSMENT AND PLAN

Christine Flores is a 63-year-old female presenting for her yearly exam.

Depression.
• Medical Reasoning: She is doing well and managing this with medication and weekly therapy.
• Medical Treatment: Continue current regimen.

Hypertension.
• Medical Reasoning: Her blood pressures have been fluctuating lately. She does admit to dietary indiscretion due to her increased workload.
• Medical Treatment: Increase lisinopril to 10 mg once daily.
• Patient Education and Counseling: She should continue to monitor this at home and follow up in 1 month.

Carpal tunnel release.
• Medical Reasoning: She is doing well 2 years postoperatively and is asymptomatic at this time.
• Patient Education and Counseling: She will contact us if her symptoms return.

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


[doctor] next patient is emily hernandez . date of birth , march 26 2001 . this is a 20 year old female being seen today for our yearly follow-up for asthma , allergic rhinitis and food allergy . due to insurance changes since our last office appointment in april 2020 , she was switched from symbicort to wixela . she also uses zyrtec in the spring , summer and fall for her seasonal allergy symptoms , which tend to work well . she also has known peanut allergy , she does tolerate almonds and cashews . please put in the asthma section at the very bottom that the act score is 21 . please put under interval history , written consent is obtained today to use dax for documentation .
[doctor] hi emily , how are you ?
[patient] i'm pretty good , how are you ?
[doctor] i'm good , thank you . so gosh , we last talked a little bit over a year ago and it was just a telemedicine visit , but it seems like you've been doing pretty good . i know there was an insurance change . i think you had switched over to wixela , is that right ?
[patient] yep , that's right , and it's what i'm currently using .
[doctor] okay , and that's the 250/50 dose , correct ?
[patient] yes , correct .
[doctor] perfect . so how does that compare ?
[patient] i mean , it's working well . i really have n't had any issues with it and i take it once in the morning and once at night .
[doctor] and that's one puff twice a day ?
[patient] mm-hmm .
[doctor] okay . and have you been having to use your albuterol inhaler at all ?
[patient] rarely , and if i do it's really just before a workout or something out that , if i know i'm really going to be pushing it .
[doctor] so it sounds like it's around strenuous activity .
[patient] yes .
[doctor] okay . so you can do things like go on a walk or going to the grocery store no problem , and just use it for more exertional stuff ?
[patient] yes . like , if i'm gon na go for a run or something like that i'll really just take it before as a preventative .
[doctor] okay .
[patient] and i've been trying to use my daily if i can a little less because i'm trying to go into the military soon .
[doctor] no kidding , that's great .
[patient] yeah , so i have to be able to operate basically at a certain fitness level without an inhaler .
[doctor] really ?
[patient] yeah , and if i can prove that i'm capable of these activities without an inhaler it makes it easier .
[doctor] and so by inhaler do they mean both your daily and rescue inhalers ?
[patient] mm-hmm . so it's like they'll have a fitness test and basically they'll tell me not to take my inhaler that day before the test , and then they'll see how the asthma affects me . and they're looking to see if it's serious enough to hold me back from joining or whatever . so i have been taking it less and less . and really some days i feel like i do n't need it .
[doctor] and that is the wixela that you're not taking . so on average per week , how many days of the week do you use one puff in the morning and one puff at night ?
[patient] probably about three or four .
[doctor] okay , three to four days per week and the other days it's once a day ?
[patient] yes , that's correct .
[doctor] okay .
[patient] and it's either in the morning or at night that i'm taking it .
[doctor] okay , and do you think that's working okay ?
[patient] i do .
[doctor] great . and any urgent care or er visits at all for breathing over the past year ?
[patient] nope .
[doctor] okay , so i'm going to assume no one has put you on prednisone for breathing issues then .
[patient] nope .
[doctor] okay . and now , military wise , what's the time frame of when you'll be completing some of these exertional tests ? like , what are your next steps ?
[patient] so , hopefully i'm going to be enlisted early spring of 2022 . so that gives me about six to seven months to get to a point where i'm able to exert my body where i do n't really need the inhaler . or at least show them that i have it under control .
[doctor] now when you were in the other room you completed a breathing test , correct ?
[patient] correct .
[doctor] okay , great . so now let me ask you about the allergies , 'cause i know typically you'll use the zyrtec in the spring , summer and fall , correct ?
[patient] yeah , i do n't really ... um , or i'm sorry , i use it more during the spring and fall . i do n't really have to use it too much in the summer .
[doctor] do you use it more just as needed in the summer ?
[patient] yeah , that's right .
[doctor] okay . and have you been taking the zyrtec every day recently since you're right in the mix of spring ?
[patient] not every day , but i do take it on days i know i'm going to be outside a lot . um , i do tend to work outside about three days a week so i'll definitely take it on those days .
[doctor] and does it seem to work pretty well still ? are you happy with it ?
[patient] yeah , it does , it works great .
[doctor] wonderful , good to hear . and then i'm assuming you're staying away from the peanuts . uh , last year you had told me it worked with ... uh , you worked with enterprise rent-a-car and one of the cars had a lot of peanuts in it that you were cleaning out and that gave you hives , uh , when you had touched it , is that correct ?
[patient] yep , that's correct .
[doctor] okay . and has there been anything like that since that experience ?
[patient] no , i do n't think so . i definitely became more cautious after that , so i usually wear , uh , wear long sleeves and change my gloves every time now . so i have n't had a reaction , but i imagine that i probably came into contact with cars that had peanuts in them , but they just d- did n't touch my skin .
[doctor] super . and it sounds like you're really smart about it .
[patient] yeah , and the airplanes , they have peanuts . they give everyone too , so .
[doctor] okay . and you have an epipen that k- that you keep with you , correct ?
[patient] yes .
[doctor] okay . and i'm assuming you're going to need refills , um , i can call you in a new set for the year . typically of course , they expire within a year .
[patient] yeah , okay .
[doctor] and i remember , um , sometime previously you've had some testing for tree nuts , but you do have almonds and cashews , correct ? and- and you do okay with them , or do you avoid all tree nuts ?
[patient] i do tend to avoid all of them but i recall eating some almonds at one point , uh , really soon after we discussed i might not be allergic to tree nuts anymore .
[doctor] okay .
[patient] and i remember having them and nothing happened , but i usually just tend to stay away from them , um , really if i can help it .
[doctor] okay . so sometimes when people have a peanut allergy , the nuts in general just are n't very important to them , so it is very common to avoid both . um , so let's do this . i'll have helen come in and i would love to complete a breathing test on you . if your breathing numbers are looking great we can work on getting you , uh , something lower than wixela . if you look at all of our asthma regimens it is a stepwise process , and wixela is a combination of two medications in one . and , well maybe you do n't need both of'em . uh , maybe you just need one of'em . so we can work our way backwards .
[patient] okay .
[doctor] and so the breathing test will help give us some- some more guidance , we will look at the results in just a moment .
[patient] all right , and so this past year i did get into the bad habit of vaping and smoking , but i have been trying to cut that out . so i should be good , and , um , now i only do just a little bit and i am trying to quit . so i am sure that might have an effect .
[doctor] it can . um , so what we can do today is compare your results with prior results , probably before you started smoking or using the vape .
[patient] okay .
[doctor] yeah . and we'll see where you stand at that point .
[patient] all right , that sounds good .
[doctor] well let me go ahead and listen , so hop on up here for me .
[patient] okay .
[doctor] all right so your ears look good , a little bit of wax on both sides . can i see inside your mouth ? big ahh .
[patient] ahh .
[doctor] good . okay let me take a peek in your nose . all right , good . you can put your mask back on .
[patient] okay .
[doctor] and go ahead take a big breath in and out . good , your lungs sound terrific . i'll listen to your heart , breathe quietly . okay very good .
[patient] awesome .
[doctor] so your breathing test is about the same as it was a couple years ago , and actually looks a little bit better . you may not remember but when we last completed the test in 2019 , uh , do you recall if you were feeling lousy at the time ?
[patient] i think it was the smoke . there were so many fires at that point and i remember coming in and looking out the window and all you saw was the orange and the smoke .
[doctor] yes , you're absolutely right , that was a bad year . that was my first fall here and i was really alarmed . well that explains why at that time your numbers were a little bit lower and today they look better . here's what i think , so you'll have kaiser currently , correct ?
[patient] correct .
[doctor] okay . most insurances do limit what we can use .
[patient] yeah i do know that .
[doctor] okay so option one would be to continue using wixela like you're using it now . we would classify it as off-label and you can use it once a day instead of twice a day , which is fine . some people do that because they just need it once a day , so that's an option . option two would be to actually back up to an inhaler that just has one med .
[patient] mm-hmm
[doctor] so the one that kaiser covers is alvesco . the thing about alvesco , though , is that it would be two puffs in the morning and two puffs at night . so it's a bit more work . um , it's not breath activated but we could step down the lowest dose to see how you do . some of the newer guidelines for asthma that were published this year is recommending trying to treat people with inhalers like wixela or alvesco only when you're ill , or say during smoke season . so minimizing their use to those periods of time versus all year . unless you found out that you're getting
[ inaudible 00:09:25 ] sick having issues every month , then that would indicate would pull back too much .
[patient] okay .
[doctor] that we had too much , yeah .
[patient] okay .
[doctor] um , so we could step back and possibly get you to the point where you just use those inhalers , uh , when you're ill or it's smoke season , but at the first step to do any of that would be to try to drop down to just alvesco .
[patient] okay , that actually sounds really good .
[doctor] okay great . so i will call that in for you , it will be the lower dose , 80 mcg , and you'll have to do two puffs twice a day .
[patient] all right
[doctor] okay and that'll be on the box when i call it in . you can put the wixela off to the side , but do n't throw it away just in case the alvesco does n't work well for you .
[patient] okay , got it .
[doctor] and then ideally we would repeat your breathing test in four months to see how you're doing , and then be able to document that you're doing well . sometimes , not always , the military will require documentation on breathing tests .
[patient] okay .
[doctor] is your pharmacy still the same or did you update it with helen ?
[patient] yeah i believe she updated it . it should be kaiser permanente broadway .
[doctor] okay perfect . i'll make sure it's the alvesco and then i'll renew your albuterol and epipen as well .
[patient] awesome , thank you .
[doctor] you're welcome . uh , then the zyrtec , do you pick it up over the counter or do get- do you get it as a prescription ?
[patient] i just get it over the counter .
[doctor] okay got it . and do you have a nebulizer that you would , uh , need refills on ?
[patient] i do n't think i need any refills , i have n't used that in such a long time . i think the last time was when i had bronchitis , or there was few select times when i had to use it when i was kid .
[doctor] okay good . well i think we have our game plan .
[patient] okay awesome .
[doctor] and do the alvesco two puffs twice a day and your albuterol if you need it . the zyrtec 10 milligrams as you need it and continue to stay away from peanuts and tree nuts and i'll refill your epipen .
[patient] okay
[doctor] all right so we've got it .
[patient] great .
[doctor] all right i'll have you take this to the front and i'm gon na say four months re-check for asthma and we'll repeat the spirometer- spirometry at that time .
[patient] okay sounds good .
[doctor] all right well thanks so much and you have a great day .
[patient] you too .
[doctor] and we'll do a follow-up in four months with act and spirometry , sooner if needed . follow-up 25 minutes .

CHIEF COMPLAINT

Follow-up for asthma, allergic rhinitis, and food allergy.

HISTORY OF PRESENT ILLNESS

Emily Hernandez is a 20-year-old female presenting today for an annual follow-up for asthma, allergic rhinitis, and food allergy. Due to insurance changes during the interim of our last office appointment from 04/2020, she was switched from Symbicort to Wixela. She uses Zyrtec in the spring, summer, and fall for her seasonal allergy symptoms, which tends to work well. She has known peanut and tree nut allergies, which she tries to avoid. She does tolerate almonds and cashew.

Mrs. Hernandez is trying to join the military, who require a certain fitness level without use of a rescue or maintenance inhaler, so she has been weaning off her inhalers. She uses albuterol prior to a run, but otherwise functions without it. She has been reducing her Wixela dose, using 1 inhalation once daily 3 times per week, with remaining days using it twice per day as prescribed. She feels this is working well. She denies urgent care or emergency room visits for respiratory issues in the past year. She denies requiring prednisone for breathing issues in the past year.

She hopes to be enlisted in the military in early spring of 2022. She is currently undergoing exertional testing to this purpose. She explains that this gives hers 6 to 7 months to show that she can exert herself without needing any inhalers.

Over the past year, she admits to vaping and smoking, though she is trying to quit and has cut down her use significantly.

She notes having a nebulizer but denies needing it recently and has only used it in her past for upper respiratory infections and as a child a few times.

Mrs. Hernandez uses Zyrtec during the spring and fall but does not typically have to use it consistently during the summer. She confirms she has been taking Zyrtec 3 days per week when she works outside, and it works well to control her symptoms.

She has been successfully avoiding peanuts. Incident from last year was reviewed where she was exposed to peanuts when she was cleaning an Enterprise rental car that had a lot of peanuts in it. She developed contact hives when the peanuts encountered her skin. Over the past year she denies additional accidental exposures. She wears long sleeves and changes her gloves between each cleaning. She thinks it is likely that she has been in contact with cars that contained peanuts, but due to her protective measures she did not touch them directly. She confirmed she always keeps an EpiPen with her.

The patient is also avoiding tree nuts. She did ingest almonds without issue following our discussion that she could try them. Despite tolerating them well, she continues to avoid all tree nuts.

PAST HISTORY

Medical
Asthma.
Allergy rhinitis.
Food allergies to peanut and tree nuts.

SOCIAL HISTORY

Currently smokes tobacco and vapes, trying to reduce and interested in cessation in preparation for joining the army.

CURRENT MEDICATIONS

Wixela Inhub 250 mcg-50 mcg/dose powder for inhalation. 1 puff 2 times daily in the morning and evening.
Proair HFA as needed.
EpiPen as needed.
Alvesco 80 mcg 2 puff 2 times daily.

ALLERGIES

Peanuts cause a severe, anaphylactic reaction.
Montelukast sodium, “seizure-like” reaction.

RESULTS

Asthma Control Test (ACT) Results: ACT score is 21.
Current food skin test sensitivities include peanuts.

ASSESSMENT

• Moderate persistent asthma, uncomplicated.
• Allergic rhinitis.
• Anaphylactic reaction due to peanuts.

Emily Hernandez is a 20-year-old female who presented today for her yearly follow-up appointment for asthma, allergic rhinitis, and food allergy.

PLAN

Moderate persistent asthma, uncomplicated
The patient has been using Wixela inhaler daily and admits to reducing her daily dose to one puff per day, 3-4 days per week as she feels she does not always need it the full dose. Additionally, she aspires to join the military and she must meet certain physical fitness requirements without the use of her inhaler. I counseled the patient on current asthma treatment guidelines which recommend using Wixela and Alvesco only when needed during periods of illness. The patient agreed to reducing her medicine to Alvesco which is a single medication, versus 2 in Welixa. The patient will continue to use her albuterol inhaler as needed. Her ACT score is 21 today and her spirometry test today was better than it was in 2019, though she recalls that it was smoky from wildfires during her last breathing test.

Allergic rhinitis
She will continue to use Zyrtec as needed, primarily during spring and fall and sometimes in summer. Her current dose cadence is 3 times per week when she works outside. Symptoms are currently under control.

Anaphylactic reaction due to peanuts
The patient has successfully avoided peanuts. Plan is to continue with current methods to avoid exposure. I will refill her EpiPen which expires annually.

INSTRUCTIONS

Moderate persistent asthma, uncomplicated
Start Alvesco, 2 puffs twice daily. Keep Wixela in case Alvesco does not work well. Continue albuterol as needed. Return in 4 months to repeat ACT and spirometry testing.

Allergic rhinitis
Continue Zyrtec 10 mg daily as needed.

Anaphylactic reaction due to peanuts
Continue strict avoidance of peanuts. I will refill her EpiPen today.


[doctor] all right , new patient , jordan roberts . date of birth : 3/2/1972 . he's a 49 year old , uh hm , with hypertension and palpitations . please copy forward his thyroid profile from march 1st , 2021 .
[doctor] hello mr. roberts , how are you doing today ?
[patient] i'm fine , thank you .
[doctor] good . good . so , i saw you were recently in the emergency room with high blood pressure and some palpitations .
[patient] yeah . that was back in march i think , but my girlfriend and i , we talked about it , and on that day i had a few cups of coffee , and no breakfast . so , i think it was probably more of a panic attack than anything else .
[doctor] yeah . have you , uh , have you felt it again since ?
[patient] uh , no .
[doctor] okay . uh , so tell me about the blood pressure then .
[patient] well , i've had issues with my blood pressure since i was young .
[doctor] do you have a family history of this ?
[patient] yeah . a lot of my family does have high blood pressure .
[doctor] i see .
[patient] yeah , i thought it was getting better , and , uh , i have a new primary doctor , and she put me on a new medication about a month ago .
[doctor] uh , can you tell me which medications you're taking ?
[patient] my new med is , uh , a combo med , something 40-25 .
[doctor] okay . um . yes , i see that in your chart . the benicar hct . it has hydrochlorothiazide in it .
[patient] yeah , that's it . my water pill i call it .
[doctor] okay . are you still taking the amlodipine , 10 milligrams daily ?
[patient] uh , yes i am .
[doctor] that's- that's a good start on a regimen . are you checking your blood pressure at home , and if yes , what numbers are you seeing ?
[patient] um , every day .
[doctor] awesome .
[patient] yeah . every morning , i take it when i get up , and it's been running at about , uh , 146 to 155 lately .
[doctor] so you're not down in the 120s yet ?
[patient] no , not yet . well , we're trying to get there though .
[doctor] okay . uh , how are you doing with your salt intake ?
[patient] i'm trying to back off of it . i think i'm doing good with it , not eating too much .
[doctor] good , uh , it plays a huge part in lowering your pressure and , uh , staying away from salt is important . um , i'll give you some information on the dash eating plan , which is the only eating plan that has been shown to lower blood pressure .
[patient] sounds good .
[doctor] are you doing any exercise ?
[patient] i do try to walk on the treadmill when i can .
[doctor] okay , great . um , all right . so , let's take a look .
[patient] all right .
[doctor] uh , you're gon na hear me talk throughout your exam , just so i can make sure i get everything documented .
[patient] okay .
[doctor] so , use my general physical exam template . let me take a listen to you and make sure everything sounds good .
[patient] all right .
[doctor] your heart and lungs sound good , so that's great .
[patient] good to hear .
[doctor] all right . go ahead and lie down . uh , and let me know if anywhere i press hurts .
[patient] nope . nowhere .
[doctor] all right . so , i'm gon na take a look at your ankles and feet . i'm just gon na look for some swelling .
[patient] all right .
[doctor] all right . it all looks good . go ahead and sit up . so , in terms of getting that pressure down , you're on three meds that are maxed out and your blood pressure is still not down . and , the question is what do we need to do to get your- to get it down . uh , your potassium one week ago was 4.0 . uh , has it been redone since in the last week ?
[patient] uh , no .
[doctor] okay . uh , four is good for your potassium level , some people have what is called resistant hypertension that is driven by something else in their body , uh , often it is a form , uh , hormonal response . if i were to take 10 people under the age of 50 who have high blood pressure who developed it at a young age , eight out of 10 would respond to reduced salt in their diet with a lower blood pressure . but , for the two out of 10 , there is something else driving it , uh , parathyroid levels or something called your adrenal glands overproduce , um , aldosterone , which we call hyperaldosterone .
[patient] okay . so , is there something we can do about it ?
[doctor] um , in these cases , there's medicine called , uh , spironolactone , that is very effective at dropping the ald- aldosterone level , and your blood pressure , and i think we should give that a try .
[patient] all right . i mean , i'm willing to give it a try .
[doctor] okay . so , let's discuss the piss- the possible risk of , uh , being on hydrochlorothiazide , which is the fluid med that you're now on . and , the spironolactone . one issue is that they can affect your electrolyte balance . um , they can also cause dehydration . so , when ... so , you got ta make sure that you hydrate . if you do not hydrate , and you get dehydrated , you will know it because you will get dizzy standing up . um , second thing is the spironolactone can raise your potassium too far , it's rare , but it can . uh , you're starting with your potassium at four , so that gives us some room .
[patient] all right . i guess that makes me feel a little bit better .
[doctor] yeah . and then the third thing is that spironolactone combined with hydrocholorozide- chlorothiazide can cause your sodium levels to go down . now , this does not mean- mean that you need to be eating more salt , okay ? but , it does mean that you will need to do blood tests in two weeks to make sure that it's okay .
[patient] all right . no , that i can do . um , are there any other side effects i need to worry about ?
[doctor] uh , dizziness possibly , as well as , uh , one in 100 guys might develop tenderness in their chest , swollen breasts , or enlarged breasts . this is a rare side effect , um , called gynecomastia , and if it happens , you just cut the medication and you let me know , but it is very uncommon .
[patient] i'll definitely let you know if that happens .
[doctor] okay . uh , we'll keep working at it until your blood pressure gets better . um , it can be tricky when your blood pressure starts to go up at a young age though , it is important to get it under control because it can lead to your heart getting bigger or enlarged . um , same thing that happens when you lift weights and your muscles get bigger , uh , and if your heart pumps against high blood pressure , it can eventually lead to heart failure .
[patient] i understand .
[doctor] yeah , so getting that under control is really important to help prevent kidney failure , strokes , and- and things like that- that you're at high risk for with high blood pressure .
[patient] okay .
[doctor] um , the american heart association has a website called heart.org , it has a lot of really good information about blood pressure to teach- to teach you about it and how to control your diet with exercise . um , if you do your treadmill routinely for 30 minutes or so most days , that could be seven to 10 points off your blood pressure .
[patient] really ? i did n't realize that .
[doctor] yeah , yeah . it's very important to be active , lower your salt , and increase your potassium . um , the goal is to keep your salt under 2000 milligrams a day , the actual recommendation is- is 1500 milligrams per day , but most people have a hard time with that . um , so just take a look at the website and the dash diet information . um , that will give you a lot of tips and information to help you start learning about this stuff .
[patient] okay . i'll definitely check that out .
[doctor] all right . so , we'll try the spironolactone and schedule a followup in two weeks to check your blood pressure and electrolytes . uh , if the new med does n't work , the next up is going to be the resistant hypertension clinic .
[patient] all right .
[doctor] all right . so , there they will look into secondary causes of your hypertension . they have access to newer procedure based technologies that can lower your blood pressure without medication , uh , for example , there is something called a renal , uh , denervation , uh , where they go inside the artery that feeds your kidney with almost like a little coil and heat that artery up . when they do that , they can block the nerve endings that get into your kidneys and lower your blood pressure .
[patient] that's interesting .
[doctor] yeah . so , that procedure has been shown to lower blood pressure by 10 points . um , there are of course some risks , so not everyone is a candidate . uh , but we'll cross that road , uh , when we need to , and let's just- let's just see how you do with the addition of the medication .
[patient] sounds good to me .
[doctor] all right . so , we will see you in two weeks then .
[patient] sounds good . thanks doc .
[doctor] yeah , you're welcome . let me know if you have any questions .
[patient] will do .
[doctor] all right . have a great day mr. roberts .
[patient] you too .
[doctor] mr. roberts presents with resistant hypertension . he's on three meds and maximum dose . i have added spironolactone to his regiment . we will need to monitor his potassium and sodium . he will have a metabolic panel and blood pressure check in two weeks . uh , next medication would be carvedilol , uh , which i try to avoid giving , it's potential for erectile dysfunction . i have talked to the patient about that , and the potential side effects of spironolactone , including the gynecomastia and electrolyte disturbances . if he is not controlled on spironolactone , the next step would be sending him to resistant hypertension clinic .

CHIEF COMPLAINT

High blood pressure and palpitations.

HISTORY OF PRESENT ILLNESS

Jordan Roberts is a 49-year-old with a long history of hypertension and an acute episode of palpitations.

In March, Mr. Roberts went to the emergency room for palpitations and hypertension. He attributed this to a panic attack, but also stated he consumed several cups of coffee on an empty stomach the morning of. He denies additional episodes of palpitations.

He has been monitoring his blood pressure at home daily, obtaining systolic blood pressure readings of 146 to 155. He does report a family history of hypertension. Additionally, he has been monitoring his salt intake and feels he is doing well at reducing it. He also walks on his treadmill as often as he can.

He has a new primary care physician who started him on a new medication Benicar HCT, which he has been using for the past month.

PAST HISTORY

Medical
Hypertension.

FAMILY HISTORY

Several family members positive for hypertension.

CURRENT MEDICATIONS

Benicar HCT 40 mg/25 mg
Amlodipine 10 mg daily.

Physical Examination

Cardiovascular
Normal rate, regular rhythm, S2 normal, normal heart sounds, and normal pulses.

Pulmonary/Chest
Breath sounds normal.

Abdominal
There is no tenderness.

Musculoskeletal
There is no edema.

RESULTS

Thyroid profile 03/01/2021.

ASSESSMENT

• Resistant hypertension.

Mr. Roberts presents with resistant hypertension, with systolic blood pressure readings between 146-155. He is currently on maximal doses for 3 medications.

PLAN

I have added spironolactone to his regimen which will require monitoring of his potassium and sodium. We will schedule him for a follow up in 2 weeks to complete a basic metabolic panel and check his blood pressure. Next medication to consider adding is carvedilol. I have tried to avoid this, given the potential for issues with erectile dysfunction. I counseled the patient about spironolactone side effects, including gynecomastia and electrolyte disturbances, as well as his increased risk of dehydration, with one sign to watch for being dizziness. If we are not able to improve his blood pressure with spironolactone, the next step would be sending him to the resistant hypertension clinic.

I provided and reviewed with Mr. Roberts the American Heart association website (heart.org) and encouraged him to access for tips on lowering his salt intake and increasing his potassium intake. His maximum salt intake should be 1500 to <2000 mg per day. He was provided materials to follow the DASH diet and encouraged to meet 30-min of walking most days.

INSTRUCTIONS

Schedule follow up appointment in 2 weeks for blood pressure check and basic metabolic panel. Reduce sodium intake to 1500 to <2000 mg per day. Follow DASH diet.


[doctor] brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl .
[doctor] she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started .
[doctor] hello , how are you ?
[patient] i'm okay .
[doctor] good . how have you been feeling ?
[patient] not so good .
[doctor] yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp .
[patient] yeah , i have .
[doctor] okay . well , your gut probably does not always appreciate that .
[patient] no , it does n't like it at all .
[doctor] yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea .
[patient] i've been getting both .
[doctor] okay . um , so how frequently have you been getting or having a bowel movement on normal days ?
[patient] i'm starting to notice it's between two and three times a day .
[doctor] okay . and are they soft stools or formed stools ?
[patient] um , they're formed .
[doctor] okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ?
[patient] yeah , i do .
[doctor] okay . do you feel it's the food or the alcohol or both ?
[patient] uh , well usually we go to friday's restaurant . i always eat pasta , the chicken alfredo .
[doctor] okay . i can s- i can bet it's the alfredo sauce .
[patient] but it normally does n't bother me .
[doctor] okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ?
[patient] no .
[doctor] okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ?
[patient] most of the time it's either tequila or dark liquor . i prefer patron , but if i get brown liquor , i only get two . um , every now and again , i'll drink a martini .
[doctor] sometimes it's the mixer they tend to put in the drinks , but it can be a variety of things . um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ?
[patient] um , no . i guess i need to find a new drink .
[doctor] okay . and how is it during the week ?
[patient] like what i eat ?
[doctor] yeah , and with the diarrhea and abdomal- um , abdominal pain .
[patient] right now , i'm still having the cramping and sharp pains , so i've been avoiding heavy foods . i did have some fried chicken today , though .
[doctor] and was everything all right after that ?
[patient] yeah , for the most part .
[doctor] okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions .
[patient] okay , good . i ca n't go out- go without some fried chicken at least once in a while .
[doctor] sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam .
[patient] sounds good .
[doctor] all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen .
[patient] okay .
[doctor] all right . do you have any tenderness ?
[patient] no , not really .
[doctor] okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you .
[doctor] all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine .
[patient] okay , that sounds good .
[doctor] okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose .
[patient] can i get a refill of that ?
[doctor] yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse .
[patient] yeah , i noticed i've been doing better with drinking water instead of sodas .
[doctor] okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water .
[patient] okay .
[doctor] okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks .
[patient] okay , i can do that .
[doctor] okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ?
[patient] i was actually going to ask you about something like that to help avoid flares altogether .
[doctor] yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ?
[patient] that sounds like a much better plan .
[doctor] okay , great . we can definitely do that . uh , just take it every night before bedtime .
[patient] okay , that sounds good . thank you so much .
[doctor] you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ?
[patient] okay , that sounds good . thank you .
[doctor] you're welcome , and have a good rest of your day .
[doctor] so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs .
[doctor] she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed .

CHIEF COMPLAINT

Follow up irritable bowel syndrome (IBS).

HISTORY OF PRESENT ILLNESS

Ms. Brittany Edwards is a pleasant 32-year-old female who returns in follow up for irritable bowel syndrome (IBS) with functional abdominal pain, nausea, and vomiting.

Ms. Edwards was last seen in August 2019 with flares of abdominal pain and was diagnosed with irritable bowel syndrome that was treated with Bentyl. She had a previous prescription for Reglan that she received from the emergency room that she used as needed for nausea. She was instructed to start a low dose fiber supplement such as Citrucel daily, probiotics to help with gas and bloating, and Bentyl up to 4 times daily for intestinal cramping. She was instructed to discontinue Reglan and to use Zofran as needed for nausea. Neuromodulators such as Elavil and Buspar were discussed but not started.

Ms. Edwards continues to have intermittent abdominal symptoms. Monday through Thursday she has less flare ups of her symptoms but states she is currently having cramps and sharp pains. She describes she recently ate shrimp which caused her to have both upper and lower abdominal pain and bloating. However, she notices episodes of diarrhea after eating chicken alfredo and consuming alcohol. She does not believe the alfredo contributes to her symptoms. The patient states she consumes 2 drinks when out of either tequila or brown liquor and occasionally a martini. She does her best to avoid “heavy foods,” but ate fried chicken today without any symptoms. She has stopped drinking sodas which has been helpful. The patient reports passing 2-3 formed stools a day.

REVIEW OF SYMPTOMS

• Gastrointestinal: Positive nausea, diarrhea, and abdominal pain.

PHYSICAL EXAM

Alert and cooperative, appears stated age.

Respiratory
Lungs clear to auscultation bilaterally.

Cardiovascular
Heart regular rate and rhythm.

Gastrointestinal
Abdomen soft, non-tender, no masses or organomegaly. Normoactive bowel sounds.

ASSESSMENT

• Irritable bowel syndrome

Brittany Edwards is a 32-year-old established patient who returned today to discuss management of IBS and functional abdominal pain made worse by high stress, poor eating habits, and poor sleeping habits.

PLAN

I have encouraged dietary and lifestyle modifications as well as starting a neuromodulator, such as Elavil 25 mg at bedtime for IBS. She can use Bentyl 20 mg as needed 30-45 minutes before eating out at a restaurant. She can also use Zofran as needed for nausea. However, I have encouraged her to reduce greasy fatty foods and alcohol consumption.

INSTRUCTIONS

Send MyChart message in 1 month regarding any side effects of issues with Elavil or if dose adjustments are needed.
Return to clinic in 1 month or sooner if needed.


[doctor] okay , so our next patient is christopher watson . date of birth 04/12/1934 . mr . watson is- is an 86-year-old male who returns in follow-up for adult hydrocephalus . this is his first visit since undergoing sh- shunt surgery , excuse me , on august 1st , 2020 .
[doctor] i have followed mr . watson since may of 2020 when he first presented with eight to ten years of progressive gait impairment , cognitive impairment , and decreased bladder control . we established a diagnosis of adult hydrocephalus with a spino catheter protocol in june 2020 , and he underwent shunt surgery on august 1st , 2020 . a medtronic strata programmable shunt in the ventricular peritoneal configuration was programmed at a level 2.0 was placed .
[doctor] good morning , mr . watson , who is the nice lady you have with you today ?
[patient] hi , doc . this is my daughter , theresa . she is the one who helps me keep things straight .
[doctor] mr . watson , have you been sick or been hosp -- hospitalized since your shu- shunt surgery three months ago .
[patient] uh , not that i recall .
[patient_guest] no , he has n't . he has been doing much better .
[doctor] good , i'm glad to hear that .
[doctor] before surgery , you were having some progressive problems that affected your walking , thinking , and bladder control . are these symptoms better , worse , or unchanged ?
[patient_guest] his walking has improved . he's now able to walk to the dining room just fine . but he could not do that before surgery . he still has times where i have to help him .
[doctor] that's impressive , mr . watson .
[patient] yeah , i guess .
[patient_guest] now his bladder control did improve some after surgery , but now seems to have leveled out . so he is wearing diapers .
[doctor] no issues with sores from wearing the diaper ? and any decreased or painful urination ?
[patient_guest] no , not at all .
[doctor] and how about cognition ?
[patient] i think i'm better . i do n't feel lost when talking to someone anymore .
[patient_guest] dad and i both think my sister , hannah , summarized it best . she said " i feel like i can have a normal conversation with him again , "
[doctor] that's so wonderful ! now have you had any headaches or pain where the shunt is ?
[patient] no . has n't bothered me one bit .
[doctor] okay . and any pain in your belly at all ?
[patient] ca n't say that i have .
[doctor] okay , sounds like you have been improving . alrighty , mr . watson , i'm going to step out of the room while my resident comes in to do a few tests for me . is that all right ?
[patient] sounds good .
[doctor] okay , i'm going to go out and review the ct scan you had last month , and then we'll chat about it when i come in .
[doctor] all righty , mr . watson , so you definitely have made some improvements since the shunt surgery . now on ct scan though i do believe i see a tiny bit of blood fluid collection in the right parietal region . now , i do n't believe that that's causing any symptoms , and i , it actually was n't documented by the radiologist when he read the ct scan .
[patient] so what does that mean ?
[doctor] just that i would like to leave the shunt set for another two to three months before we go in changing it . like i said , if you're not having any headaches or pain and you have improved so that's all good for me . so really there's , there's nothing to worry about .
[patient] all right so i'll come back in three months ?
[doctor] yep , that's right .
[patient] i do have a question for you though .
[doctor] yeah , of course .
[patient] do you think i will be able to drive again ?
[doctor] ah man , mr . watson , i knew you were gon na ask me that one . i think at this point it's unlikely that your movement speed will improve to the level that would be needed for you to pass the driver safety evaluation . now , i will say that i do occasionally have patients who surprise me by improving over a nine to 12 month range . and that , that definitely could be you . you could definitely pass it at that point . so if you improve and we can continue to talk about that then , ya know , i think it could be possible , um , and i'd be happy to recommend it .
[doctor] now , you could definitely also enroll in a driver safety program without my recommendation . so you could kind of do that preemptively , and then we could continue to watch for your improvement as we go .
[patient] okay . i kinda figured that anyway but i just thought i'd ask . i do n't like to burden anyone when i just need to run to the store but i also know that i need to be safe .
[doctor] yeah , your safety is our number one priority and , ya know , i'm sure your daughters do n't mind as much , right , they want to keep you here and have you safe . but , i overall am very pleased with how much you have improved . and so , i'm sure when we talk again in three months , we'll continue to be on that upward trajectory or improvement .
[patient] i sure hope so , doc .
[patient_guest] we really appreciate all that you've done . do we make the appointment out front ?
[doctor] yeah , that would be great . the girls up front will take care of you and get you settled for three months from now , and you both take care , all right ?
[patient] thanks
[patient_guest] thank you .
[doctor] all righty , so ros is constitutional significant for impaired ability to carry out daily functions . negative for fever or unintentional weight loss . gu is significant for urinary incontinence and wearing a diaper . negative for genital sores , decreased or painful output . neurological significant for continued walking impairment and cognitive impairment . negative for headaches , recent falls , or hallucinations . psychiatric is negative for depression , excessive worrying , or mood swings .
[doctor] let's go ahead and use the short pe . vitals , let's see , blood pressure is 124/80 , heart rate 64 , respirations 18 , weight 174 pounds , and pain zero out of 10 .
[doctor] mr . watson is a pleasant and cooperative man who's able to converse easily through , um , though his daughter does add some details . the shunt sight was clean , dry , and intact with a confirmed setting of two . um he was tested um for recent and remote memory , attention span , and concentration in fund of knowledge . he scored a 26 out of 30 on the mmse when tested with spelling and 25 out of 30 when tested with calculations . of note , he was able to get two of the three memory words with cuing , and the third with multiple choice . this was a slight improvement over his initial score of 23 out of 30 with calculations and 24 out of 30 with spelling . and at the time he was unable um in the previous test , excuse me , he was unable to remember any memory words with cuing without and only one with multiple choice .
[doctor] gait testing using the tinetti assessment tool . he was tested without an assistive device and received a gait score of six to eight out of 12 and a balance score of 12 out of 16 for a total score of 18 to 20 out of 28 . this is slightly improved from his initial score of 15 to 17 out of 28 .
[doctor] cranial nerves , pupils are equal . eoms are intact . face symmetric . no disarchria . motor normal for bulk and strength . coordination slow from no- finger to nose . of note , the ct scan from the head of 10/15/2020 shows a frontal horn span at the level of foramen of monro of 4.6 centimeters with a third ventricular contour that is flat with a span of 10 millimeters . by my reading there is a tiny amount of blood in the right front region with a tiny subdermal collection . this was not noticed or noted by the radiologist who stated any extra axial fluid collections . there is also substantial small vessel ischemic change .
[doctor] diagnosis adult hydrocephalus , gait impairment , urinary incontinence and urgency , and cognitive impairment .

CHIEF COMPLAINT

Follow up adult hydrocephalus, 3 months status post shunt surgery.

HISTORY OF PRESENT ILLNESS

Mr. Christopher Watson is an 86-year-old male who returns in follow up of adult hydrocephalus. This is his first visit since undergoing shunt surgery 08/01/2020. He is accompanied by his daughter, Theresa, together they give his history.

I have followed Mr. Watson since May 2020. He presented with 8-10 years of progressive gait impairment, cognitive impairment, and decreased bladder control. We established a diagnosis of adult hydrocephalus with the spinal catheter protocol in June 2020 and he underwent shunt surgery on 08/01/2020. A Medtronic Strata programmable shunt in the ventriculoperitoneal configuration programmed at level 2.0 was placed.

Mr. Watson has had no hospitalizations or other illnesses since I last saw him. With respect to his walking, his daughter states that he is now able to walk to the dining room just fine but could not before his surgery. His balance has improved though he still has some walking impairment. With respect to his bladder control, initially there was some improvement, but he has leveled off and he wears a diaper. With respect to his cognition, both Theresa and the patient say that his thinking has improved. The other daughter, Hannah summarized it best according to the two of them, she said “I feel like I can have a normal conversation with him again.” Mr. Watson has had no headaches and no pain at the shunt site or in the abdomen.

PAST HISTORY

Urinary incontinence.
Adult hydrocephalus.
Gait impairment.
Cognitive impairment.

REVIEW OF SYSTEMS

• Constitutional Symptoms: Significant for impaired ability to carry out daily functions. Negative for fever or unintentional weight loss.
• Genitourinary: Significant for urinary incontinence and wearing a diaper. Negative for genital sores, decreased or painful output.
• Neurological: Significant for continued walking impairment and cognitive impairment. Negative for headaches, recent falls, or hallucinations.
• Psychiatric: Negative for depression, excessive worrying, or mood swings.

VITALS

Blood pressure 124/80, heart rate is 64, respiratory rate is 18, weight 174 pounds, and pain is 0/10.

PHYSICAL EXAM

Constitutional
Mr. Watson is a pleasant and cooperative man who is able to converse easily though his daughter adds some details.

Head and Face
The shunt site was clean, dry, and intact and confirmed at a setting of 2.0.

Neurological
Mental status: Tested for recent and remote memory, attention span, concentration, and fund of knowledge. He scored 26/30 on the MMSE when tested with spelling and 25/30 when tested with calculations. Of note, he was able to get two of the three memory words with cuing and the third one with multiple choice. This was a slight improvement over his initial score of 23/30 with calculations and 24/30 with spelling and at that time he was unable to remember any memory words with cuing and only one with multiple choice.
Gait: Tested using the Tinetti assessment tool. He was tested without an assistive device and received a gait score of 6-8/12 and a balance of score of 12/16 for a total score of 18-20/28. This has slightly improved from his initial score of 15-17/28.
Cranial Nerves: Pupils are equal. Extraocular movements are intact. Face symmetric. No dysarthria.
Motor: Normal for bulk and strength.
Coordination: Slow for finger-to-nose.

RESULTS

CT scan of the head from 10/15/2020: It shows a frontal horn span at the level of foramen of Munro of 4.6 cm with a 3rd ventricular contour that is flat with the span of 10 mm. By my reading, there is a tiny amount of blood in the right frontal region with just a tiny subdural collection. This was not noticed by the radiologist who stated no extra axial fluid collections. There is also substantial small vessel ischemic change.

ASSESSMENT

• Adult hydrocephalus.
• Gait impairment.
• Urinary incontinence and urgency.
• Cognitive impairment.

Mr. Watson has made some improvement with his hydrocephalus since shunt surgery. There is a tiny fluid collection in the right parietal region. I do not believe that this tiny amount of fluid is symptomatic, and it was not documented by the radiologist when he read the CT scan.

Mr. Watson asked me about whether he will be able to drive again. Unfortunately, I think it is unlikely that his speed of movement will improve to a level that he will be able to pass a driver's safety evaluation, however, occasionally patients surprise me by improving enough over 9 to 12 months that they are able to pass such a test. I would certainly be happy to recommend such a test if I believe he is likely to pass it and he is always welcome to enroll in a driver's safety program without my recommendation, however, I think it is exceeding unlikely that he has the capability of passing this rigorous test at this time. I also think it is quite likely he will not regain sufficient speed of motion to pass such a test.

PLAN

I had a long discussion with the patient and his daughter. We are all pleased that he has started to make some improvement with his hydrocephalus because of the fluid collection in the right parietal region, I would like to leave the setting at 2.0 for another three months before we consider changing the shunt.

INSTRUCTIONS

Follow up in 3 months.


[doctor] amanda taylor , birth date october 31st 1949 . patient is a 72 year old woman who comes for followup for hypertension . her history includes significant alcohol use disorder and mi- mild hypercholesterolemia . at last visit on april 16th her blood pressure was 130 over 90 . after presenting at 150 over 100 she was prescribed hydrochlorothiazide 12.5 milligrams by mouth once daily , and lisinopril 20 milligrams by mouth once daily . cmp and cbc were essentially unremarkable .
[doctor] hi miss taylor , how are you today ?
[patient] hi , i'm- i'm good , thank you .
[doctor] thanks for coming in today .
[patient] yeah , no problem .
[doctor] so how have things been going for you ?
[patient] uh , they've been all right . i'm struggling with not drinking . i wanted to discuss that , uh , shot that you had mentioned last time , but we did n't get to discuss it too much .
[doctor] okay , well i'll be happy to provide you with more information . so tell me when did you last have a drink ?
[patient] on monday .
[doctor] okay , so you've gone a couple days without it ?
[patient] yeah , yeah i have .
[doctor] yeah , and had you been drinking for a while ?
[patient] yep .
[doctor] how much had- how much had you been drinking ?
[patient] um , four or five times a week hard alcohol , so , you know .
[doctor] okay . well it will certainly help your blood pressure if you're able to stop drinking .
[patient] yeah , yeah i- i- i agree with you .
[doctor] okay . are you taking your blood pressure medications ?
[patient] yeah , but i'm only taking half of the lisinopril .
[doctor] okay .
[patient] i- b- well , the first time i took it i felt lethargic and tired , so i only took a half dose the next time . i felt much better and i did n't have the headaches or the swooshing that started in my left ear . so i feel like it's definitely helping but i do n't know ... i know it's not gon na be okay until i stop drinking .
[doctor] and are you also taking the full dose of the hydrochlorothiazide ? do you have any , um , chest tightness or pressure or any shortness of breath ?
[patient] yeah i'm taking the full dose of that medicine too , and no none of those symptoms .
[doctor] okay . anything else i should be aware of or that we should be checking ?
[patient] mm , no .
[doctor] okay , good . are you doing the blood pressure checks at home ?
[patient] yes . yes i am .
[doctor] okay good . what kind of numbers are you seeing ?
[patient] well , in the morning i'm seeing lower numbers than in the evening , um , where i run anywhere from like 130 to 145 or 150 over 95 to 100 on the bottom .
[doctor] okay .
[patient] but in the evenings if i sit there for a while and then take it , it goes down . kind of like when i come here it's always high but then it goes down . in the mornings it's generally more normal where it's supposed to be .
[doctor] uh- .
[patient] mm , also i'm taking my medicine in the morning when i get up instead of in the evening .
[doctor] yeah , so it sounds like we are not too far out of where we wan na be .
[patient] right , mm-hmm .
[doctor] okay . well let me get a listen to your heart , go ahead and hop up here .
[patient] okay .
[doctor] use my general exam template . all right , go ahead and take some deep breaths . okay , good . any fever , cough , shortness of breath or sore throat ?
[patient] no .
[doctor] any recent travel or contact or exposure to the coronavirus ?
[patient] nope .
[doctor] have you received your coronavirus vaccine ?
[patient] yes , on february 9th .
[doctor] okay , great . all right well i'm just going to look at your ankles and feet , i'm looking for any signs of swelling .
[patient] okay .
[doctor] all right , well everything looks good . you can go ahead and sit up miss taylor . all right , so the good news is everything is looking okay . i think we both agree if you were able to stop drinking your blood pressure would cease to be an issue for you .
[patient] yeah i agree with that .
[doctor] so let us discuss the potential medicine to help you with that . what it does is it blocks some of the brain receptors that alcohol stimulates and it tricks the brain into thinking it does not need alcohol , thereby cutting down the urges .
[patient] the urge to drink or the constant thinking about it ?
[doctor] it actually will help with both .
[patient] okay . so is it like a one-time thing ?
[doctor] generally the shot is given about once a month , it can also be given as a daily pill , but the shot does tend to work a bit better .
[patient] yeah i've taken things like this in the past and if it is a pill , i know i wo n't take it . with a shot , it's not like you can un-take it .
[doctor] yeah that's true . and the shot has been shown to work , it is more just a matter of getting you in to get your shot a month later with the nurse .
[patient] yeah , sure , sure .
[doctor] okay , so it's called naltrexone . i think the other name might be vivitrol . like i've said , the research on it is pretty good .
[patient] i think i may have taken the naltrexone before .
[doctor] okay , yeah , maybe you have .
[patient] yeah , if it was available in a pill form then i'm almost certain i've tried it b- before .
[doctor] okay . if this sounds good though , we can go ahead get you started with the shot . i am looking and it looks like we have you coming back in on may 17th for your first shot , does that sound good ?
[patient] yeah , yeah , that sounds great . are there any possible side effects ?
[doctor] yeah , some people will experience some nausea , headache , dizziness , anxi- anxiety , tiredness and trouble sleeping , but generally the side effects are mild and should go away within a few days .
[patient] okay .
[doctor] then we can schedule you for a follow-up in june to see how you are doing .
[patient] all right that sounds good .
[doctor] all right great . well otherwise stay with your current medicines , keep checking your blood pressure , and let's see if we can stop the alcohol for good . let us know if you have any questions or any issues come up after you receive the first dose .
[patient] all right , sounds good , thank you .
[doctor] you are welcome , have a good rest of your day .
[patient] you too .
[doctor] miss taylor is drinking alcohol four to five days per week to excess . no tobacco , no substance abuse , skin is moist , good trigger . on exam she is alert , pleasant , in no acute distress . she is not diabetic , there is no tremor , no cva tenderness , chest clear to percussion and auscultation , unlabored breathing , cardiac rhythm regular , no murmur , no gallop , jvp flat , with a head at 90 degrees . she does not appear anxious , agitated or depressed . my impression , alcohol use disorder . she would like to start naltrexone which we have previously discussed . she will take the injectable form and start on may 17th . we reviewed side effects and risks . the potential benefit of alcohol cessation would be highly beneficial to her for many reasons . hypertension , she is taking lisinopril 10 milligrams daily and hydrochlorothiazide 12.5 milligrams daily . quite possibly her blood pressure will improve completely with cessation of alcohol . her target bp is 130 to 140 over 70 to 80 . i will see her back week of june 14th , which is likely around the time of her second naltrexone injection . i recommend upgrading influenza vaccination and shingrix . number two , she did defer this .

CHIEF COMPLAINT

Hypertension.
Alcohol use disorder.

HISTORY OF PRESENT ILLNESS

Amanda Taylor is an 72-year-old woman who presents for a follow-up for hypertension. History includes significant alcohol use disorder and mild hypercholesterolemia. At last visit on April 16, BP was 130/90. After presenting at 150/100 she was prescribed hydrochlorothiazide 12.5 mg by mouth once daily and lisinopril 20 mg by mouth once daily. CMP and CBC were essentially unremarkable.

Mrs. Taylor admits to consuming alcohol 4-5 times a week and is interested in Naltrexone injections. She acknowledges that her blood pressure would likely improve if she stopped alcohol consumption. She is checking her blood pressure in the morning and evening, stating it is higher at night but will improve after sitting for a few minutes. She is averaged 135-145 or 150 over 95-110.

She experienced side effects from lisinopril, such as headaches, “swooshing” in her left ear, and lethargy. She took half a dose and did not experience the side effects.

PAST HISTORY

Medical
Hypertension.
Hypercholesterolemia.
Alcohol use disorder.

CURRENT MEDICATIONS

Lisinopril 20 mg tablet once daily.
Hydrochlorothiazide 12.5 mg once daily.

PHYSICAL EXAM

Constitutional
No distress. No fever. No tobacco or other substance use.

Neurological
Alert.

Psychological
She does not appear anxious, agitated or depressed.

Neck
JVP flat with a head at 90 degrees.

Respiratory
No cough or shortness of breath. Chest clear to percussion and auscultation. Unlabored breathing.

Cardiovascular
No CVA tenderness. Cardiac rhythm regular. No murmur. No gallop.

Musculoskeletal
No ankle edema.

Integumentary
Skin is moist. Good trigger.

ASSESSMENT

• Alcohol use disorder.
• Hypertension.

Mrs. Taylor presents for a follow-up for hypertension. History includes significant alcohol use disorder and mild hypercholesterolemia. At last visit on April 16, BP was 130/90. After presenting at 150/100 she was prescribed hydrochlorothiazide 12.5 mg by mouth once daily and lisinopril 20 mg by mouth once daily. CMP and CBC were essentially unremarkable.

PLAN

Alcohol use disorder
I will start her on naltrexone which we have previously discussed. She will take the injectable form and start on May 17. We reviewed side effects and risks. The potential benefit of alcohol cessation would be highly beneficial to the patient.

Hypertension
She will continue taking lisinopril 10 mg/day and hydrochlorothiazide 12.5 mg daily. Quite possibly her blood pressure will improve significantly if she is able to completely stop consuming alcohol. Target BP is 130-140/70-80. I will see her back week of June 14 which likely will be the time of her second naltrexone injection.

Recommend upgrading influenza vaccination and Shingrix #2, she defers this.

INSTRUCTIONS

Call the clinic with any questions. Make follow up appointment week of June 14th.


[doctor] next patient is grace ross . date of birth 8-23-97 . ms. ross is a new patient . she's here today for a full spectrum std testing . the patient states that she's having symptoms of discomfort , a change in discharge , and odor in her vaginal region . she says that the right side of her vagina is starting to become painful . she denies any fevers or chills . she reports , that she recently learned , her partner has been in sexual encounters with other people , and she wants to be evaluated for all stds .
[doctor] hello , ms. ross . i'm dr. diaz . it's good to meet you .
[patient] hi . yes . nice to meet you , too .
[doctor] so , how are you doing today ? i hear that you're here for std testing . is that correct ?
[patient] yeah . actually , i found out earlier this week , that my boyfriend has been cheating on me , for some time . i'm really worried , that i could have caught something , you know ?
[doctor] mm-hmm .
[patient] i wanted to make sure i do n't have anything .
[doctor] yeah . i'm sorry to hear that . of course , we can do that today . um . well , let's see . how do you feel ? do you have any symptoms ?
[patient] well , um , i started noticing some weird discharge last week .
[doctor] mm-hmm .
[patient] uh , it smells different . it's not the same color , or consistency , as usually , it is .
[doctor] right .
[patient] um . that part did n't even phase me , until i noticed that the right side of my vagina was hurting . just sore , you know , but that has n't gone away .
[doctor] yep . nah , that does sound like a cause for concern . how long have you been with him ?
[patient] hmm , we've been dating for three years .
[doctor] mm-hmm .
[patient] as far as , i can figure , he started cheating on me , i think , about three months ago .
[doctor] uh- . um , okay . do you ... have you ever had an irregular pap smear ?
[patient] well , yeah , i did , but it was back whenever i was 20 or so . it has n't ... and i have n't had one since .
[doctor] okay . and when was your last pap smear ?
[patient] uh , about six months ago . it came back normal , though .
[doctor] okay . good , okay . well , let's see ... let's take a look at you , and then , we'll get some samples for std testing . okay ?
[patient] all right .
[doctor] you'll hear me talk through your exam , so that i can get it all documented . uh- ?
[doctor] use my general physical exam template . pelvic exam demonstrates no external lesions . normal labia majora and labia minora . normal physiological discharge , with normal color and smell .
[doctor] ms. ross , i'm going to touch you , now . you'll feel my fingers , and the speculum in your vagina . you'll feel some pressure , now .
[doctor] cervix is normal . vaginal wall is normal . no cervical motion tenderness and no adnexal tenderness or masses noted . swabs were done for std testing .
[doctor] okay , ms. ross . everything looks good from a visual standpoint . i'm going to send off std testing for , uh , gonorrhea , chlamydia , trichomoniasis , and i'll have you give some blood for syphilis , hiv and hepatitis c. some of these tests will take longer than others . we will call you , if we see anything , but if you have n't heard anything , you can call us in three days for results .
[patient] okay . sounds good . thank you , so much .
[doctor] of course , my pleasure . and , if everything is normal , i'll see you again , at your next annual checkup .
[doctor] assessment : is screen for std .
[doctor] plan : discussed with patient , and please add that she is high risk due to an abnormal pap smear in the past , and the recent discovery of her sexual partner having multiple partners , for some period of time .
[doctor] end of recording .

CHIEF COMPLAINT

Full-spectrum sexually transmitted disease testing.

HISTORY OF PRESENT ILLNESS

Ms. Ross is a 23-year-old female who presents today as a new patient for full-spectrum STD testing.

The patient states that she is having symptoms of discomfort, a change in discharge, and an odor in her vaginal region. She says that the right side of her vagina is starting to become painful but denies any fever or chills. She states that she recently learned her partner of 3 years has been engaging in sexual encounters with other people for quite some time, and she wants to be evaluated for all sexually transmitted diseases.

Ms. Ross reports noticing a change in the odor, color, and consistency of her vaginal discharge last week. She notes that this did not alarm her until the right side of her vagina became painful and sore, which has not subsided. She states that she had an abnormal Pap Smear around the age of 20, but all her Pap Smears since then, including her most recent one approximately 6 months ago, have all been normal.

PHYSICAL EXAM

Genitourinary
Pelvic exam: No external lesions, normal labia majora and labia minora. Normal physiological discharge with normal color and odor. Cervix is normal, vaginal wall is normal, no cervical motion tenderness or masses noted. Swabs were obtained for sexual transmitted disease testing.

ASSESSMENT

• Screening for sexually transmitted disease.

PLAN

Ms. Ross is a 23-year-old female who presents today as a new patient for full-spectrum STD testing. We will screen her today for gonorrhea, chlamydia, trichomoniasis, syphilis, HIV, and hepatitis C. Patient is high risk due to an abnormal pap smear in the past and the recent discovery of her sexual partner having multiple partners for some period of time. We will call the patient with the results of the laboratory testing.


[doctor] tyler nelson , date of birth : 3 , 6 , 1949 , mrn , 385729 . he is here today for ongoing management of rheumatoid arthritis . last time he was here , he received a steroid injection in his right knee . hello mr. nelson , how are you ?
[patient] um , about the same as last time . my knee is still swollen .
[doctor] that was your right knee , correct ? i take it the injection did n't help ?
[patient] it did , maybe for a couple of weeks .
[doctor] that's it ? and is it still painful ?
[patient] yeah , it's pretty painful , and now the whole leg is getting swollen .
[doctor] okay , what would you say your pain level is ?
[patient] i mean , right now it's about a 3 or so , but , typically on a normal day it's around 6 .
[doctor] okay , and its been swollen like that for how long now ?
[patient] since i was last here a couple weeks after that . so about , maybe two months now .
[doctor] okay , but before it was just the knee ?
[patient] yeah , the whole thing was n't swollen like this , but i tried to wear compression socks a lot of the time , but it has n't been helping .
[doctor] okay , okay , so that has n't been working for you ?
[patient] i mean , it helps to some degree , but it's still swollen , especially around the knee .
[doctor] hmm . has it been keeping you from doing things during the day ?
[patient] well , i slowed down a little bit , and i found a few things too fast . but when it really hurts , is when i've been sitting for a while , and then i have to try and get up . i'm so stiff getting up i have to use a cane to get my bearings . i mean , after a little bit , it loosens up , but that first getting up is real difficult .
[doctor] yeah , i can see , that makes sense . have you been taking your medication regularly ? your on xeljanz right ?
[patient] yeah , the xr , i think its , uhm , 11 milligrams a day ? yeah , but i'm taking it everyday , and i'm also taking celebrex which i started maybe 2 months ago .
[doctor] yes , the 200mgs daily . how's that working for you ?
[patient] pretty good , up until it started swelling again .
[doctor] okay , well come sit over here , and if you could take of your socks and shoes , and we'll take a look at your knee . and just to let you know , i have a service now that writes my note about the visit , so you'll hear me call things out and describe what i see fully .
[patient] okay , gotcha .
[doctor] right , so let's check your leg . can you straighten it , and does it hurt ?
[patient] yeah , when i try to straighten it all the way it does .
[doctor] okay , range of motion slightly diminished . i'm going to press here , okay ? and how about here , hmm , i see some pitting around the knee and ankle . normal capillary refill in the toes . does any of this area hurt ?
[patient] um , just kinda sore , like an old bruise ?
[doctor] so , i can feel that the knee is hot , and that means there's something going on , like some inflammation . so we can give you another steroid injection for that . i also want to get an x-ray of that knee , so we can see where all the swelling is coming from .
[patient] yeah . let's do it . sounds go to me .
[doctor] okay , and did we set up physical therapy for you last time you were here ?
[patient] yeah , that was some years ago , but that was the other knee .
[doctor] okay . so i think we'll set that up for you now . we'll also do an x-ray on that knee . i can send you for a physical therapy , and if nothing is helping , then we really might need to get a surgery consult to see what we can do with that knee .
[patient] okay , sounds like a plan .
[doctor] all right , so for today we'll go ahead and we'll give you the steroid shot . i'll try to see if i can get a little bit of fluid out before i do give you the injection . there might be no fluid , but i'll see if i can get anything out regardless .
[patient] okay . and that's a procedure you're going to do right now ?
[doctor] yep . once we're done talking here , and as far as the edema in your legs , uh , we'll take an x-ray to look for the cause , but there is a lot you can do as well . the compression socks are a good start . um , and also , do you eat a lot of salt ?
[patient] i mean , um , i mean i love my salty snacks .
[doctor] okay . well , salt does have a tendency to make your body hold on to water , reducing your salt intake could help with some of the swelling . you can also prop your feet up any time you get a chance , especially at night . and have you talked to your private care doctor about this at all ?
[patient] no , i figured i would just come here first .
[doctor] okay . so i think , try some of those things out first , and if it does n't help , definitely make an appointment with them , also , as you know , xeljanz is a high-risk medication , so we need to check your cmp levels every couple of months . so this time your levels are good , but do make sure to make an appointment for the blood work for next time .
[patient] all right . i can do that . thank you so much doc .
[doctor] yes , of course . well let me go ahead and get supplies and we'll get to work on your knee .
[doctor] fluid aspiration and steroid injection procedure . the risks , benefits , and alternatives were explained . the risks of steroid injection were explained , including , but not limited to : hypopigmentation , soft tissue atrophy , tendon ruptures , and transient hypoglycemia among others . verbal consent was attained . the right knee was , uh , um , accessed through the lateral approach with 3 milliliters of initially clear fluid , then bloo- blood tinged fluid . then the right knee was prepped in a standard-fashion . the right knee was injected with 80 milligrams of triamcinolone , and one milliliter of lidocaine . the procedure was tolerated well , with no complications . post-procedure instructions were given . patient will follow up with his pcp . thank you .

CHIEF COMPLAINT

Rheumatoid arthritis management.

HISTORY OF PRESENT ILLNESS

Mr. Nelson is a 72-year-old male who presents today for ongoing management of rheumatoid arthritis. He was last seen by me on 03/04/2021, where he received a steroid injection to his right knee. He continues to experience right knee pain and swelling. The pain level is 6/10. He notes when he stands after he has been sitting for a while, he has to use a cane to "get his bearings." The injection he received to the right knee at the last visit was only beneficial for a few weeks. The patient notes whole right leg swelling since the last visit. He usually wears support hose, which helps to some degree. He has not attended physical therapy.

PHYSICAL EXAM

Musculoskeletal
Lower right extremity: Swollen right knee, slightly reduced range of motion. Skin warm to touch. Lower right leg pits with pressure.

PROCEDURE

Fluid aspiration and Steroid injection.
Risks, benefits, and alternatives were explained. The risks of steroid injection were explained, including but not limited to, hypopigmentation, soft tissue atrophy, tendon ruptures, and transient hyperglycemia among others. Verbal consent was obtained. The right knee was accessed through the lateral approach with 3 mL of initially clear fluid then blood-tinged fluid. Then the right knee was prepped in a standard fashion. The right knee was injected with 80 mg triamcinolone and 1 mL lidocaine. The procedure was tolerated well with no complications. Post procedure instructions were given.

ASSESSMENT

• Rheumatoid arthritis management.
• High risk medication use.
• Right knee pain.
• Lower extremity pitting edema.

PLAN

Rheumatoid arthritis management.
The patient will continue Xeljanz XR 11 mg daily. He will also continue Celebrex 200 mg daily.

High-risk medication use.
The patient is currently on the high-risk medication Xeljanz. We will check his CMP levels and monitor periodically every couple of months.

Right knee pain.
He has right knee pain and swelling, with pain level 6/10. On exam today, the right knee continues to be hot, which is ongoing inflammation. We performed a fluid aspiration of the right knee today, see procedure note above. A steroid injection to the right knee was given today, see procedure note above. We will arrange for x-ray of the right knee and refer his to physical therapy.

Lower extremity pitting edema.
The patient notes whole right leg swelling since the last visit. He usually wears support hose, which helps to some degree. He has not seen his PCP. We discussed compression stockings, elevate feet, and a low salt diet. He will check with his PCP for further instructions.