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

CHIEF COMPLAINT

Right knee injury.

HISTORY OF PRESENT ILLNESS

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

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

SURGICAL HISTORY

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

MEDICATIONS

She denies needing medications.

REVIEW OF SYSTEMS

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

PHYSICAL EXAM

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

RESULTS

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

ASSESSMENT

1. Right knee posterior cruciate ligament strain.

PLAN

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

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


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

CHIEF COMPLAINT

Recurrent lung infections.

SOCIAL HISTORY

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

ALLERGIES

Patient denies history of seasonal allergies.

REVIEW OF SYSTEMS

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

VITALS

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

PHYSICAL EXAM

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

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

Musculoskeletal
- Examination: No clubbing.

RESULTS

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

ASSESSMENT AND PLAN

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

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


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

CHIEF COMPLAINT

Asthma.

MEDICAL HISTORY

Patient reports history of asthma.

SURGICAL HISTORY

Patient reports history of tonsillectomy.

SOCIAL HISTORY

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

ALLERGIES

Patient reports history of seasonal allergies.

MEDICATIONS

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

REVIEW OF SYSTEMS

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

PHYSICAL EXAM

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

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

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

ASSESSMENT AND PLAN

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

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

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

INSTRUCTIONS

The patient will follow up in 6 weeks for recheck.


[doctor] carolyn is a 34 -year-old female with a history of diabetes mellitus type two who is here today with a headache so hi there carolyn it's nice to see you again listen i'm sorry you're having headaches well let's talk about it but i would like to record this conversation with this app that's gon na help me focus on you more would that be okay with you
[patient] yes that's okay
[doctor] okay great thanks so carolyn tell me about your headache and headache or headaches when did when did they start and and what symptoms are you having
[patient] my headache started about a week ago it's feeling like a dull pain in the back of my head i have flushing in my ears they get really red and hot and sometimes i just feel a little bit dizzy when i get these headaches but i've taken tylenol and advil and it's not really going away it just keeps coming back
[doctor] okay and alright and so this started about a week ago has it been fairly constant since it started or does it come and go does it come and go or what
[patient] it comes and goes i it it's relieved when i take my tylenol or advil but then it comes right back
[doctor] hmmm okay and do you notice any any timing difference you know is it is it worse in the morning worse in the evening is there anything else that makes it better or worse
[patient] it's definitely worse in the evening
[doctor] okay and do you feel any sort of tightness in the back of your neck or in your shoulders or you know you said it's in the back of your head primarily any discomfort anywhere else
[patient] yes no just in the back of my head
[doctor] okay and did the headache start all of a sudden carolyn or has it been gradual or what
[patient] i've been under a lot of stress lately so maybe about when some stress started occurring
[doctor] okay okay and alright and have you noticed any fever along with the headache
[patient] no no fever
[doctor] okay and any visual changes you know wavy lines in your vision spots in your vision or anything like that
[patient] no
[doctor] okay and have you had headaches like this before
[patient] i have
[doctor] okay so this is n't the worst headache you've ever had what did you say
[patient] no it's not
[doctor] okay alright and so okay fair enough now how's your diabetes been been been doing lately have you what have your blood sugars been running in the low one hundreds or two hundreds or what
[patient] i have n't been checking my blood sugars
[doctor] really okay well we will get you back on that and and we can talk about that but how about your metformin are you still taking the five hundred milligrams once a day no actually it looks like we increased your metformin to five hundred milligrams twice a day last visit are you still taking that
[patient] yes
[doctor] okay great and okay you're still watching your diet and getting some exercise
[patient] i have not been eating well because i've been stressed over the last week but i have n't been exercising for maybe the past week but generally i've been doing better
[doctor] okay the headache has has maybe made you feel uncomfortable and prevented your your exercise would you say or what
[patient] yes it has
[doctor] okay okay so you probably have n't been out golfing i remember you're a big golfer so not not lately uh so you know being
[patient] not lately
[doctor] being down being down here in florida we got ta get get some golf in so hey did you see the masters by the way a few weeks ago was n't that i do n't know did you happen to catch it
[patient] i did
[doctor] yeah that was crazy what a what a finish what an amazing what an amazing tournament right what do you think yeah yeah that's great well we'll we'll get you feeling better and get you back out there and now are you still working a lot on the computer ac or
[patient] i am
[doctor] carolyn okay yeah you're still working a lot on the computer for work okay are you taking breaks every hour or so you know get up stand around walk stand walk around that can be helpful
[patient] no i really do n't get the opportunity to
[doctor] hmmm okay understood alright well listen let's go ahead and examine you okay so so on your physical exam your physical exam is pretty normal unremarkable for the most part and you know few things a few exceptions so first of all on your heent exam your eye exam your extraocular motions are intact without pain you have a funduscopic exam that shows no papilledema that's good that just means there's no swelling in the back of your eye and on your neck exam you do have some posterior mild posterior paraspinal muscular tenderness in the cervical spine and in bilateral trapezius musculature as well and some tightness in those muscles as well and otherwise on your exam let's see your heart exam on your heart exam you have that grade three out of six systolic ejection murmur that's unchanged from your prior exam so it just means i hear some sounds in your heart as it's beating and i'm not too worried about that we'll watch that and otherwise normal heart exam and and your physical examination otherwise is normal and unremarkable and so now let's talk about my assessment and your plan so carolyn for your first problem of the headache i do think that you have a tension type headache and i think this because you've got some tension and tightness in your paraspinal muscles meaning the muscles around your neck and your shoulders and you know working at the computer i think is contributing to this and also probably the stress so you can continue to take that tylenol for the pain i'm also gon na give you a mild muscle relaxant i'll write you for flexeril five milligrams three times a day and you can take that that will help relax those muscles in your neck and that should help with the symptoms i want you to come back or give us a call if the headaches become more severe or suddenly worsen or you develop a fever but i do n't think that this is a a sign of a stroke or any bleeding in your brain or anything like that i think it's more related to tightness in your muscles in your neck now for your second problem of your diabetes mellitus let's continue you on the metformin five hundred milligrams i am going to order a hemoglobin a1c and also a cbc and a chem-12 to check some of your blood tests blood chemistries and so forth and we will continue you on the metformin i do want you to check your blood sugars daily and that will be very helpful so when you come back in a month i want you to bring those numbers with you we can talk about it again and please do try to get back into your exercise routine that's really gon na help you keep those blood sugars under control as well okay so how does that sound for a plan any other questions for me
[patient] well would it so only call if if it gets worse or not any better
[doctor] yeah that that just right but also let's set up an appointment in four weeks and i wan na see you back in four weeks if it's not if the headache is not better within the next few days with this flexeril then you can give us a call and and get back in later this week or early next but definitely if things get worse give us a call sooner and you know i meant to ask you on i wanted to ask if you had a history of any any trauma meaning have you hit your head or you have n't fallen hit your head or anything like that have you
[patient] no no i think it's just stress
[doctor] okay alright understood okay great well then i'll see you back in a month if not before okay you take care of yourself nice seeing you
[patient] thank you
[doctor] sure

CHIEF COMPLAINT

Headache.

MEDICAL HISTORY

Patient reports history of diabetes mellitus type 2.

SOCIAL HISTORY

Patient reports she enjoys golfing.

MEDICATIONS

Patient reports taking metformin 500 mg twice a day.

REVIEW OF SYSTEMS

Constitutional: Denies fever.
Eyes: Denies vision changes.
HENT: Reports ear flushing.
Neurological: Reports headaches and dizziness.

PHYSICAL EXAM

Eyes
- Examination: No papilledema.
- Extraocular Muscles: Grossly Intact without pain.

Neck
- General Examination: Mild posterior paraspinal muscular tenderness in the cervical spine and bilateral trapezius musculature as well tightness.

Cardiovascular
- Auscultation of Heart: Grade 3 out of 6 systolic ejection murmur that is unchanged from prior exam.

ASSESSMENT AND PLAN

1. Headache.
- Medical Reasoning: Patient presents with symptoms similar to a tension headache. On exam she has tension and tightness in her paraspinal muscles as well likely due to working at the computer. Additionally, I think her stress level is also a contributing factor.
- Patient Education and Counseling: I discussed the diagnosis with the patient today. I explained that her headaches may be caused by tension around the muscles around her neck and shoulders. I advised her that her symptoms do not appear related to signs of a stroke or brain bleeding. Questions were asked and answered today.
- Medical Treatment: She can continue to take Tylenol for the pain. Prescription for Flexeril 5 mg 3 times a day is provided as well.

2. Diabetes mellitus.
- Medical Reasoning: Due to her headaches, she has been inconsistent with her exercise and checking her blood sugar.
- Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. We also discussed the importance of keeping a watchful eye on her blood sugar levels.
- Medical Treatment: She will continue taking metformin 500 mg daily. Order for hemoglobin A1c, CBC, and CMP provided today. She will check her blood sugar daily and will bring that information in on her next visit.

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

INSTRUCTIONS

The patient will follow up in 1 month. She can follow up or call sooner if her headaches become more severe or suddenly worsen or she develops a fever.


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

CHIEF COMPLAINT

Right knee pain.

HISTORY OF PRESENT ILLNESS

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

MEDICAL HISTORY

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

SOCIAL HISTORY

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

MEDICATIONS

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

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain.

PHYSICAL EXAM

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

RESULTS

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

ASSESSMENT

Right knee pain, possible medial collateral ligament strain.

PLAN

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

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

INSTRUCTIONS

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


[patient] hey bruce so see here my my notes here is you here he had positive lab work for hep c so how're you doing today
[doctor] i'm doing okay but i'm a little bit anxious about having hep c i've really surprised because i've been feeling fine they had done it as you know a screen as just part of my physical so i'm really surprised that that came back positive
[patient] okay so in the past have any doctors ever told you that you had hep c
[doctor] no never that's why i'm i'm so surprised
[patient] okay so just you know i need to ask do you have a history of iv drug use or you know have known any hep c partners
[doctor] i mean i used to party a lot and even did use iv drugs but i have been clean for over fifteen years now
[patient] okay that that's good i mean i'm i'm happy that you were able to to kick that habit i know a lot of my patients that i see you know they're still dealing with with those dements so i'm i'm i'm happy that you're able to do that so hopefully we can get you better okay
[doctor] thank you
[patient] so what about alcohol use is that something that you used to do a lot
[doctor] i did i did i mean i i still have a beer here and there everyday but not as much as i used to
[patient] okay and have you ever smoked before
[doctor] i do smoke i smoke about one to two cigarettes per day i've cut down a lot but i'm just having a hard time kicking those less too
[patient] yeah yeah and that that's something i've got to work on too because hep c along with smoking you know both of those are n't are n't good so hopefully we can help you out you know if your pcp has n't prescribe something for you already and possibly we can we can do that for you as well
[doctor] okay
[patient] so do you have any other medical conditions
[doctor] no i'm actually other than that i just had my physical and i'm not taking any medications no i'm i'm pretty good otherwise
[patient] okay and what conditions would you say run in your family
[doctor] i have high blood pressure diabetes and depression
[patient] okay
[doctor] alright so let me go ahead and do a quick physical exam on you so i reviewed your vitals and everything looks good and on general appearance you appear to be in no distress no jaundice on the skin on your heart exam you have a nice regular rhythm rate
[patient] regular rate and rhythm with a grade two out of six systolic ejection murmur is appreciated on your lung exam your lungs are clear without wheezes rales or rhonchi on your abdominal exam bowel sounds are present your abdomen is soft with no hepatosplenomegaly
[doctor] hepatosplenomegaly yes let me i will change that one
[patient] splenomegaly and on your muscle exam there is no gait disturbance or edema so i did we i was able to review your your results of your recent lab work and your hcv antibody test was positive so your your liver panel we did one of those and it showed an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so that's pretty good so let's talk a little bit about my assessment and plan for you so you do have hepatitis c so your initial labs were consistent with that hep c diagnosis and so you know i do n't know if you read much about hep c but hepatitis c is a viral infection that does affect your liver and you've most likely had it for several years now it it it most patients do n't see symptoms until years later so the next step that i would like to do is just confirm the diagnosis with some additional blood work so that includes checking your hep c rna and your hcv genotype and i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and we will do that by ordering an ultrasound elasto elastography with this information we will we we will be able to know how we can proceed as far as treatment right so how does that sound
[doctor] i hmmm so i do have a wife and kids so should i be worried about them
[patient] okay yeah so we can start with the same screening that you had for august first so we'll just let's do that hep c antibody test and i'll actually help you set up those appointments with your your family doctor and then we can just see you back in three weeks and based on the results you know we will take action as needed okay
[doctor] okay that sounds good
[patient] alright
[doctor] alright
[patient] my nurse will be in with those those orders
[doctor] alright thank you
[patient] alright thanks
[doctor] bye

CHIEF COMPLAINT

Hepatitis C.

HISTORY OF PRESENT ILLNESS

Bruce Ward is a pleasant 60-year-old male who presents to the clinic today following a positive result in a hepatitis C antibody test. He was sent to obtain the hepatitis C antibody test as part of a routine physical. He states he is anxious with the results and denies he has ever been diagnosed with hepatitis C. The patient admits to intravenous drug use in the past; however, he notes it has been longer than 15 years since his last usage. He also reports a history of heavy alcohol use. He continues to drink a beer on occasion. The patient currently smokes 1 to 2 cigarettes per day. He notes he used to smoke more and is having difficulty with complete cessation.

MEDICAL HISTORY

The patient denies any significant past medical history.

SOCIAL HISTORY

The patient is married with children. He reports history of IV drug use 15 years ago. He currently drinks beer occasionally. The patient reports smoking 1 to 2 cigarettes per day.

FAMILY HISTORY

He reports a family history of high blood pressure, diabetes, and depression.

MEDICATIONS

Patient denies taking any current medications.

VITALS

All vital signs are within normal limits.

PHYSICAL EXAM

CONSTITUTIONAL: In no apparent distress.
CV: Regular rate and rhythm. Grade 2 out of 6 systolic ejection murmur is appreciated.
RESPIRATORY: Lungs are clear without wheezes, rales, or rhonchi.
GI/GU: Abdomen is soft with no hepatosplenomegaly. Bowel sounds are present.
SKIN: No jaundice.

RESULTS

The HCV antibody test was reviewed today and is positive.

Liver panel revealed an elevated AST at 39 U/L. The ALT, albumin, and total bilirubin were all within normal limits.

ASSESSMENT

Hepatitis C.

PLAN

After reviewing the patient's laboratory findings today, I have had a lengthy discussion with him in regard to his current symptoms. His initial labs were consistent with a hepatitis C diagnosis. I have recommended that we confirm the diagnosis with additional blood work including checking his hepatitis C RNA and HCV genotype. I have also recommended that we obtain an ultrasound elastography to evaluate for fibrosis of the liver.

The patient is married with children and is concerned about their hepatitis C status. I advised the patient that his family should be screened and we will assist him with setting appointments with their primary care physician.

INSTRUCTIONS

The patient will follow up with me in 3 weeks to review his results and discuss further treatment.


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

HISTORY OF PRESENT ILLNESS

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

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

MEDICAL HISTORY

Patient denies a history of blood transfusions.

SOCIAL HISTORY

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

FAMILY HISTORY

Patient denies a family history of immune deficiencies.

REVIEW OF SYSTEMS

Gastrointestinal: Denies abdominal issues or diarrhea.

VITALS

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

PHYSICAL EXAM

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

RESULTS

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

ASSESSMENT

IgA deficiency.

PLAN

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


[doctor] how are you doing
[patient] i'm doing i'm good i'm i'm doing really good i'm here i'm just ready to quit smoking and but i've been having quite a hard time with it
[doctor] well i'm glad that you're taking the first steps to quit smoking would you tell me a little bit more about your history of smoking
[patient] yeah so i've been smoking for some time now i started in high school and was just you know just experimenting and smoking here and there with friends or at parties and then it just started getting more regular and regular and i do n't even know how i'm 44 now and i'm smoking everyday so yes now i'm up to a pack and a half a day
[doctor] okay do you use any other type of tobacco products
[patient] no smoking is enough
[doctor] okay and i understand that so when you wake up in the morning how soon after waking up do you smoke your first cigarette
[patient] i would say probably within an hour of waking up i'll have my first cigarette
[doctor] okay so i'm really excited that you wan na quit and i know that you probably heard this multiple times before but this really is one of the best things that you can do to help your health especially since you have the history of gout and type two diabetes this is really gon na be a great step in you having better long term health outcomes
[patient] yeah i know and you know i'm really motivated now because i am about to be a father any day now and i just really wan na be there for my daughter growing up
[doctor] hey that's great and that's great to hear congratulations i'm so excited to hear about the new baby
[patient] yeah
[doctor] i i have a daughter myself have have you picked out any names
[patient] we're you know we're deciding between a few names but we're kinda just waiting to see her to see which name fits
[doctor] okay alright that sounds good well congratulations again i'm very excited for you and your and and your wife that that's this is great
[patient] thank you
[doctor] so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried
[patient] yeah actually i just went cold turkey one day i woke up and i said you know i've had enough and i know that smoking is not good for me so i woke up and stopped and i actually did really well and i was able to quit smoking for almost a year and then things just started getting really stressful at work they started laying people off and i'm happy i still have a job but that also meant that i was responsible for more things so things just got stressful and i and just started picking it up again
[doctor] well you are absolutely correct you know stress can often be a trigger for things like smoking and drinking have you thought what you would do this time when you encountered the stressful situations
[patient] yeah i i did n't think about that a lot actually and one thing is i have started learning and trying to do more meditation and then i also just recently joined the gym so i'm really looking forward to working out again
[doctor] okay well that's great to hear that you're getting back in the gym that will be good for your long term health too you know helping to maintain that type two diabetes you know those are really great strategies talking about gym for stress relief and and you know we have other products as well that you can use for an additional aid to help you stop smoking have you given any thought to using some type of smoking cessation aid at this time or or what do you think about that
[patient] you know i've had you know because i've been trying to do cold turkey and it's not working and some of my friends actually have mentioned using a patch and they they've had some success with that so i think i would i would probably wan na start with that
[doctor] okay alright that that sounds good it's good that you've you've picked out one of those aids and have you thought of a quit date i mean we we really wan na talk about when you're gon na say this is the day
[patient] yeah you know next monday is actually my birthday so i think that's a good day
[doctor] that's a fantastic day and happy birthday coming up on monday
[patient] thank you
[doctor] so let's talk a little bit about your exam here okay i'm gon na go ahead and do a quick physical exam and i reviewed your vitals and everything looks good including your oxygen saturation blood pressure for today was one twenty eight over eighty eight heart rate was sixty eight respirations were sixteen and your pulse ox was ninety eight percent on room air so those were all really good now on your heart exam you do have a nice regular and your your rate is of regular rate and rhythm or i'm sorry your heart exam for your heart exam notice that your heart is regular in rate and rhythm i do however still appreciate that two over six systolic murmur that we talked about in the past now that's okay we'll just continue to monitor that now for your lung exam i'm gon na go ahead and listen to your lungs your lungs are clear and equal bilateral with no expiratory wheezes and no rales or rhonchi are appreciated on your neck exam i do n't appreciate any lymphadenopathy when i listen i do n't hear any extra noises so i do n't hear any hearing any carotid bruit which is a good thing now for my impression and plan let's talk a little bit about my assessment and plan for you so for your first problem of nicotine dependence first of all i just want to apply you on making this first step to stop smoking and i want you to know with absolute one hundred percent certainty that i'm gon na be with you every step of the way i think it's fantastic that you're very welcome i i i think it's fantastic you've chosen next monday as a quit date and on that day i'm gon na start you with a twenty one milligram nicotine patch and the goal will be to decrease that over time okay now we will work together to decrease that so there is no necessarily hard dates in mind okay be sure to change the patch location each day and that's going to help reduce or avoid that skin irritation that can occur if you use the same location over and over again i would like to see you again in two weeks just to see how things are going and we will reevaluate at that time the dosage for your nicotine patch now we also see further need to discuss any handouts you received today for those common smoking triggers i really want you to keep an eye on and monitor your stress level not only about work but also the fact that you are experiencing are going to be be a new father and we really want to watch any stress you will be experiencing around the birth of your new child so please keep an eye on that and let me know how that goes now for now until we meet in two weeks go ahead and keep up your exercise routine i think that's a great plan and just try to monitor your stress and and maybe think about some things like meditation or adding in some yoga and that type of thing to help further work with your your stress levels so do you have any questions for me
[patient] no not at this time
[doctor] okay so for your other conditions that we talked about briefly your second condition of type two diabetes we'll let's go ahead and continue to maintain that with diet and exercise and we'll just monitor your type two diabetes i am gon na go ahead and order a hemoglobin a1c for your next blood draw since i'll see you in two weeks go ahead and have that done and we will talk about that when you come back in now for your third problem of your history of gout let's go ahead and continue you on your allopurinol and just you know continue to watch those foods that will exacerbate your uric acid levels any other questions about those
[patient] no i think that's it thanks so much
[doctor] alright sounds good i'll see you in two weeks congratulations on the baby and and we're excited about next monday that's your quit date
[patient] alrighty thank you
[doctor] you're welcome i'll see you in two weeks thanks bye-bye
[patient] alright bye

CHIEF COMPLAINT

Smoking cessation.

MEDICAL HISTORY

Patient reports a history of type 2 diabetes, gout, and a 2/6 Systolic ejection murmur.

SOCIAL HISTORY

Patient reports he is a smoker.

MEDICATIONS

Patient reports taking allopurinol.

VITALS

Oxygen Saturation: 98% on room air.
Blood Pressure: 128/88 mmHg.
Heart Rate: 68 beats per minute.
Respiratory Rate: 16 breaths per minute.

PHYSICAL EXAM

Neck
- General Examination: Neck is supple without lymphadenopathy. No carotid bruits.

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

Cardiovascular
- Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur.

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

ASSESSMENT AND PLAN

1. Nicotine dependence.
- Medical Reasoning: The patient has a long history of smoking cigarettes. He is currently smoking 1.5 packs per day. He is highly motivated to cease smoking as he is preparing to become a father.
- Patient Education and Counseling: I applaud the patient on making this first step to stop smoking. I reassured him that with absolute 100% certainty that I will be with him every step of the way. I explained to the patient that stress can often be a trigger for smoking. He received handouts today for common smoking triggers. I advised him to be watchful and monitor his stress level, not only regarding work, but also his impending fatherhood. The patient and I discussed coping mechanisms for when he encounters stressful situations. I encouraged him to maintain his gym routine, engage in meditation, and try adding in yoga to help further reduce his stress levels. We discussed additional cessation aids.
- Medical Treatment: The patient has chosen his birthday, as a quit date. On that day, I am going to start him with a 21 mg nicotine patch, and the goal will be to decrease that over time. We will work together to decrease the dosage of the nicotine patch, so there are not necessarily any hard dates in mind. I recommend he change the patch location each day as that will help reduce or avoid any skin irritation that can occur if he re-uses the same location repeatedly.

2. Type 2 diabetes.
- Medical Reasoning: Stable.
- Patient Education and Counseling: We discussed that continuing to follow a healthy diet and perform regular exercise will help to maintain his blood glucose levels.
- Medical Treatment: We will continue to monitor his type 2 diabetes. Hemoglobin A1c is ordered to be completed by his next visit in 2 weeks.

3. History of gout.
- Medical Reasoning: Stable with medication.
- Patient Education and Counseling: I advised him to continue to watch for foods that will exacerbate his uric acid levels.
- Medical Treatment: He will continue his allopurinol.

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

INSTRUCTIONS

I would like to see him again in 2 weeks to discuss how things are going and to reevaluate the nicotine patch dosage.


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

CHIEF COMPLAINT

Left-sided back pain.

MEDICAL HISTORY

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

MEDICATIONS

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

REVIEW OF SYSTEMS

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

VITALS

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

PHYSICAL EXAM

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

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

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

RESULTS

Previous hemoglobin A1c is reviewed at 7.3.

ASSESSMENT AND PLAN

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

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

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

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


[doctor] alright you can go ahead
[patient] hey alan i good to see you today so i looked here my appointment notes and i see that you're coming in you had some shoulder pain left shoulder pain for the last three weeks so
[doctor] how you doing is it is it gotten any better
[patient] yeah yeah i've been having a lot of pain of my shoulder for the last three weeks now and it's not getting better okay do you remember what you were doing when the pain first started
[doctor] so i i was thinking that i i ca n't recall like falling on it injuring it getting hit
[patient] hmmm
[doctor] i have been doing a lot of work in my basement and i even i put in a new ceiling so i do n't know if it's from all that activity doing that but otherwise that's that's all i can think of
[patient] okay so do you remember hitting it or anything like that
[doctor] no nothing at all
[patient] okay alright did you fall do you remember doing that
[doctor] no
[patient] okay hmmm so like a little mystery so have you had pain in that shoulder before
[doctor] i mean i'm very active so i can get pains in my shoulders but it's nothing that sometime some tylenol can help
[patient] okay and are you able to move the arm or is it kinda just stuck
[doctor] i'm having a lot of pain like i can move it but you know when i try to reach for something lifting anything and even like i do n't even try to put my hands over my head because it causes so much pain
[patient] alright so does that pain radiate anywhere or like where would you say it is in your shoulder
[doctor] it actually it stays pretty much just right at the shoulder it does n't go down anywhere
[patient] okay and the pain is it is it all the time or does it come and go
[doctor] it's pretty much all the time anytime i put any pressure on it like when i'm trying to sleep it hurts even more so it's been affecting my sleep as well
[patient] okay so i know you mentioned tylenol so this time i have n't taken anything for it
[doctor] yeah i i do the tylenol which usually works for me and it does take the edge off but i still have pain okay did you try icing it at all
[patient] i iced it initially but i have n't iced it at all recently
[doctor] alright
[patient] and so with your shoulder have you experienced any numbness in your arm or in your fingers
[doctor] no numbness or tingling
[patient] okay good so i'm gon na go ahead and do a quick physical exam and take a look at your your shoulder so i reviewed your your vitals everything looks good with that so touch here in your shoulder so your left shoulder exam you have limited active and passive range of motion so pressure here so that there is tenderness of the greater
[doctor] okay
[patient] tuberosity of the humerus let's see there is no tenderness at the sternoclavicular or acro
[doctor] yeah
[patient] acromioclavicular joints
[doctor] yeah yeah
[patient] and looks like you have good hand grip let me see so on the neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is is intact to light touch
[doctor] yes thank you yep
[patient] so you did get a we get we had to get a x-ray of your shoulder before you came in and so it's normal so that's really good so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you you do have that left shoulder pain so your symptoms are
[doctor] most likely due to a rotator cuff tendinopathy so this means that you injured tendon you have injured tendons and muscles that make up your shoulder and make up your shoulder muscles so what i'm gon na do is i'm gon na order an mri of your left shoulder
[patient] and so we're gon na begin with that just to make sure nothing else is going on have you done physical therapy before
[doctor] i have n't
[patient] okay so what i'm gon na do i'm going to refer you to physical therapy for approximately six to eight weeks and so they can help you strengthen those muscles around your shoulder and that should definitely help with the pain during that time you can also continue to take tylenol i do n't think i need to prescribe anything else for the pain you said as it's working pretty good for you so if your symptoms do n't improve we can consider a steroid injection of your shoulder which should provide some relief but i think right now we can just go with the the pt and hopefully that works to alleviate your injury so do you have any questions about the plan
[doctor] so like i said i'm really active do you think that this pain will ever go away
[patient] yeah so many patients are very successful with rehab and so we'll start with that and see how you do most most of the time once we build up those muscles around that shoulder you know things things the pain alleviates itself and and and you will be good to go back to working on your basement and running and jogging and lifting weights all all the active things people do these days
[doctor] okay alright thank you
[patient] bye
[doctor] okay bye

CHIEF COMPLAINT

Left shoulder pain.

HISTORY OF PRESENT ILLNESS

Alan Mitchell is a pleasant 69-year-old male who presents to the clinic today for the evaluation of left shoulder pain. The onset of his pain began 3 weeks ago, without any improvement. He denies any specific injury; however, he has been renovating his basement and putting in a new ceiling. He does not recall hitting or falling onto the left shoulder. The patient states he is very active and has experienced left shoulder pain before that usually resolves with Tylenol.

The patient reports significant pain with reaching, lifting, and overhead activities. The pain is constant. He states the pain is primarily located in the left shoulder and denies it radiates down into the left arm. The patient also reports difficulty sleeping secondary to the pain. He denies any numbness or tingling in his left arm or fingers. He has been taking Tylenol for pain, which provides partial relief. He initially iced his shoulder but has not iced it recently. The patient denies he has done any physical therapy.

REVIEW OF SYSTEMS

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

VITALS

All vital signs are within the normal limits.

PHYSICAL EXAM

MSK: Examination of the left shoulder: Limited active and passive ROM. Tenderness over the greater tuberosity of the humerus. No tenderness at the sternoclavicular or AC joints. Good hand grip. Neurovascularly intact distally. Capillary refill is less than 3 seconds. Sensation is intact to light touch distally.

RESULTS

X-rays of the left shoulder were obtained and reviewed today. These are normal and reveal no fracture or bony abnormalities.

ASSESSMENT

Left shoulder pain, likely rotator cuff tendinopathy.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding his current symptoms. I have explained that his x-rays did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the left shoulder to evaluate for possible rotator cuff tendinopathy. The patient was provided with a referral to formal physical therapy. He will engage in a 6-to-8-week course in order to strengthen his left shoulder. I have also advised him to take Tylenol as needed for pain. If his symptoms do not improve, we may consider a steroid injection to the left shoulder.

INSTRUCTIONS

The patient will follow up with me once the MRI results are available for review and further discussion.