[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] hi virginia how are you today what brings you in
[patient] i'm doing alright i started seeing this new pcp last year and you know she has been doing a lot of changes to my medication and making sure everything is up to date and she my noticed that my blood pressure has been quite high so she added to medications but and but i you know i've been taking them i've been really good and i i before i was n't but now i am and we're still having a hard time controlling my blood pressure so she thought it would be a good idea for me to see you especially since she noted some on my last blood work she said something about my kidneys
[doctor] okay yeah so okay let's before i dive into a lot of that tell me a little bit about how you've been feeling
[patient] i would say you know most of the days i feel fine i'm still busy at work i definitely can tell though when my blood pressure is high
[doctor] okay you measure it at home you you you measure your blood pressure at home
[patient] yeah i she wanted me to get a blood pressure cuff so i did start getting checking my blood pressures probably like a few times a week
[doctor] okay
[patient] and so then i noticed that it has been getting higher the other day was even as high as one seventy over ninety
[doctor] wow
[patient] so i did call my pcp and she increased the meds again
[doctor] yeah okay now i i just have a couple questions about that are you using a an electronic blood pressure recorder or do you have somebody help you at home
[patient] yeah she i have a a electronic one an electronic arm one
[doctor] okay okay yeah that's good that's good and have you ever tried do you go to cvs at all
[patient] yeah i i do but i've noticed like since the pandemic i do n't see the blood pressures anymore
[doctor] okay okay yeah i i thought the one down on main street they i thought they just brought that one back so
[patient] did they
[doctor] yeah
[patient] that's good to know
[doctor] you may wan na check that but okay so that's good but i what i'd like you to do with that is i'd like you to keep a record of them for me for my next visit with you so let's talk a little bit about your diet tell me how how is your diet what what are the what kind of foods do you like what do you eat normally
[patient] alright do you want the honest answer
[doctor] well yeah that would be better
[patient] so i really you know with everything going on i really been trying to get better but i mean during football season it's really difficult i really love watching my games so have a lot of pizza wings subs like i said i've been trying to cut down especially on days where there is no games but it probably could be better
[doctor] okay i think we all can say that but i do wan na just hey i do n't know that if you've tried it or not but there is a new restaurant down on fifth street and it is nothing but solids and i you know when i heard this i was like okay yeah it's just another these solids are absolutely amazing so if you ever get a chance yeah if you ever get a chance try try that i mean i think you would enjoy them because they're salads that they make are just out unbelievable so let me go ahead and i just have a few more questions and i'm gon na just ask these in in order and you just tell me and then we will come back and talk about them do you have any headaches
[patient] really just when my blood pressure gets really high i have some mild headaches but otherwise i do n't have it on a regular basis
[doctor] okay what about chest pain
[patient] no chest pain
[doctor] shortness of breath
[patient] no shortness of breath
[doctor] even with exertion
[patient] even with exertion
[doctor] okay do you have any swelling in your lower extremities at all that you noticed
[patient] not if i'm on my feet for a long time i'll notice a little bit of swelling but otherwise no
[doctor] okay and then a couple other family history questions anybody in the family have kidney disease or significant high blood pressure
[patient] both my parents do have high blood pressure and one of them did have kidney disease
[doctor] okay okay and in the the the form that you filled out when you came in it says that you are on ten milligrams of norvasc daily and carvedilol twenty five milligrams twice a day is those the medicines you're on
[patient] yes i was also on lisinopril before but with the adjustments yeah those are the ones i'm on
[doctor] okay and so here's where i think we are going to go do you take any nonsteroidals like advil or motrin or aleve
[patient] yeah just once in a while for my like any knee pain or back pain that i have but again not like everyday
[doctor] okay and then lastly what kind of alcohol intake do you have you know do you consider how many drinks a week is really what i'm looking for
[patient] i'll have a couple of beers during the week and like one or two on the weekends
[doctor] okay okay so lem me do a quick physical examination so i looked at your vitals when you came in today and your blood pressure it's still high it's one sixty nine over seventy four your heart rate was eighty eight and your oxygenation was ninety eight percent so those are all fairly good except that blood pressure's a little higher than we'd like to see now when i look at your neck i do n't see any jugular vein distention and i'm gon na listen here real quick no i do n't hear any carotid bruits i'm gon na listen to your lungs okay your lungs are clear and let me listen quickly to your heart i do hear that a two over six systolic ejection murmur and we'll we're gon na have to take a little bit look extra look at that that's when i i can hear an extra sound when i'm listening to your heart and you do have a small amount of one plus pitting edema bilaterally now i did so you do have that your diagnosis is uncontrolled hypertension you know and i think you're aware that that's what your your physician's been treating you for and most of the time this cause is is the cause of this is multifactorial it's not that there is just one thing causing it so we may need to be changing your medicine around and i'm gon na talk to your doctor but first thing before we make any more medication changes i want to order some tests first to rule out if there is any specific cause for this so first order will be a renal artery ultrasound and what i'm looking for there is that there is no areas of areas of narrowing in the the blood vessels of your kidneys that would be the cause of your hypertension in addition to that i'm gon na order a you get another urine collection some morning aldosterone levels reining levels and a twenty four hour urine and these things can really show me if there is any problems with your adrenal glands again this is a lot of big words but you know i'm i i'll write this all out for you i want you to decrease your alcohol i know you like those beers but let's bring it down to maybe one a week or two a week just to get those down lower and then your salt intake you need to be very judicious about decreasing that salt intake i'm gon na give you a referral to a nutritionist to discuss those changes for that you need and and they will help you get that cleared up and then finally stop taking any nonsteroidal medicines such as your advil or motrin the only thing i really want to want you taking is tylenol for any pain right now i am gon na prescribe one medicine and that's cardura four milligrams and i want you to take that once a day and that's good to see if that can help us with your blood pressure and then finally three weeks i'd like you to return i want you to record all of your blood pressures that you take over the next three weeks and bring them into the office but most importantly if you can try to take them at the same time everyday that would be beneficial for me any questions for me
[patient] no i i just it's a lot so i i'm hoping this will work and this will get it under control
[doctor] yeah i i think you know this will be you know this we're gon na spend some time together so i'm glad to have you as a patient but you know we got ta try to get this under control and i'm gon na i'll be talking to your pcp just to let them know that you know what my plans are and we'll stay real in sync on treating this as we move forward does that sound like a plan
[patient] that sounds good thank you
[doctor] okay take care i'll talk to you later
[patient] okay alright bye

CHIEF COMPLAINT

High blood pressure.

SOCIAL HISTORY

Patient reports drinking a couple of beers during the week and approximately 1 to 2 on the weekend. She is employed.

FAMILY HISTORY

Patient reports both of her parents have hypertension and one also had kidney disease.

MEDICATIONS

Patient reports taking Norvasc 10 mg daily and carvedilol 25 mg twice daily. She occasionally takes anti-inflammatories.

REVIEW OF SYSTEMS

Cardiovascular: Denies chest pain or dyspnea on exertion.
Respiratory: Denies shortness of breath.
Musculoskeletal: Denies bilateral lower extremity edema.
Neurological: Reports headaches.

VITALS

BP: 169/74.
HR: 88 bpm.
SpO2: 98%.

PHYSICAL EXAM

Neck
- General Examination: No jugular vein distension. No carotid bruits.

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

Musculoskeletal
- Examination: 1+pitting edema in the bilateral lower extremities.

ASSESSMENT AND PLAN

1. Hypertension, uncontrolled.
- Medical Reasoning: The patient's elevated blood pressure is consistent with uncontrolled hypertension.
- Patient Education and Counseling: We discussed the nature of the diagnosis and that this is typically multifactorial. I advised the patient that further testing should reveal additional information. She was encouraged to reduce her intake of alcohol as well as her salt intake. I recommended that she stop taking anti-inflammatories and use Tylenol as needed for pain. We also discussed the importance of home blood pressure monitoring of the next 3 weeks to see if the medication is beneficial.
- Medical Treatment: Renal artery ultrasound ordered. Urine collection, morning aldosterone levels, renal levels, and a 24-hour urine were also ordered. Referral to nutritionist provided. Prescription for Cardura 4 mg once a day provided as well.

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

INSTRUCTIONS

The patient will follow-up in 3 weeks and will bring her blood pressure log with her.


[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 teresa what's going on i heard that i heard that you're having a sore throat you're not feeling well
[patient] yeah my throat has been hurting me for like four four days now and i think i had a fever last night because i was really sweaty but i did n't take my temperature because i was already in bed
[doctor] okay alright so four days ago you started feeling badly okay now were you having chills
[patient] yeah last night i was chills and i had lot of sweating and it's really hard to swallow
[doctor] it's really hard to swallow okay now do you have pain every time you swallow or is it just periodically
[patient] every time i swallow i'm even having trouble eating i can drink okay the like really cold water feels good
[doctor] okay that's what i was gon na ask you okay so you're able to drink water and are you able to drink any other fluids have you been able to drink any you know i do n't know juices or milk shakes or anything like that
[patient] well besides my wine at night i really just drink water all day
[doctor] okay well i like to drink wine too what's your favorite type of wine
[patient] peanut grooves yes
[doctor] it's a good one i like that too i am also a pino navar fan so there you go alright well let's now do you feel sick to your stomach at all
[patient] no i have a little bit of a stuffy nose not too bad it's really just my throat but i think my tonsils are swollen too
[doctor] and your tonsils are swollen too now has anyone else sick in your household
[patient] i do have little kids that go to school so they've always got you know those little runny noses or cough but nobody is really complaining of anything
[doctor] okay alright now have you had strep throat in the past
[patient] when i was a kid i had strep throat but i have n't had anything like that as an adult
[doctor] okay alright and what do you do for work
[patient] i i work as a cashier in a supermarket
[doctor] okay alright and did you get your covid vaccine
[patient] yep i did get my covid vaccine but it really made me feel sick so i'm hoping i do n't have to get another one later this year
[doctor] okay did so you just got the two vaccines you did n't get the booster
[patient] no i did n't get the booster because i really have n't had time to feel that sick again it really knocked me down for like two days and with the little kids it's really hard
[doctor] okay alright well i saw that they did a rapid covid test when you came in here and that was negative so that's good so you do n't have covid which is which is good now let's talk a little bit about your hypertension and hypertension since i have you here did you ever buy that blood pressure cuff that i asked you to buy
[patient] yes i did i blood the blood pressure cuff and my blood pressure is like all over the place sometimes it could be like one twenty for the top number sometimes it could be one forty for the top number i i do n't really remember the bottom number though
[doctor] okay that's okay are you taking the lisinopril i think we have you on twenty milligrams a day
[patient] yep i take it every morning with my multivitamin and my vitamin d
[doctor] okay alright and are you watching your salt intake
[patient] i really like my chips with my wine
[doctor] is n't that the best we we could get along really well outside of here alright and then tell me a little bit about your diabetes now are you are you watching your blood sugars are you taking them at home
[patient] sometimes i take that all that often again that could be all over the place sometimes i get if i take it first thing in the morning it'll be like eighty or ninety but at night sometimes it could be one forty
[doctor] okay alright and i are you still taking the metformin we have you on a thousand milligrams twice a day
[patient] uh uh yes i do take it i take it with my breakfast and with my dinner
[doctor] okay alright great alright now are you are you a meds fan or a yankie's fan or god for a bit of filly's fan
[patient] nope
[doctor] no
[patient] no do n't do n't like sports
[doctor] do n't like sports just the wine
[patient] no
[doctor] okay alright well let's go ahead i wan na just do a quick physical exam now i'm gon na be calling out some of my findings and i'm gon na let you know what that means when i'm done okay so looking here first at your vital signs your vital signs look pretty good you do have a low-grade fever of about a hundred . four right now but otherwise your blood pressure is pretty good it's about one thirty two over eighty and your heart rate is eighty four now that looks pretty good so i'm just gon na go ahead and examine you so on your facial exam i'm gon na just press on your face here does this hurt
[patient] no not no it does n't bother me
[doctor] okay on facial examination the patient has no pain to palpation of the frontal or maxillary sinuses on nasal examination there is edema and erythema of the nasal turbinates bilaterally with associated clear discharge open up your mouth and say
[patient] ah
[doctor] on throat examination there is bilateral erythema and edema of the peritonsillar space with exudates present bilaterally the uvula is midline on your neck exam i do appreciate some cervical lymphadenopathy on the right hand side on your lung exam your lungs you have some coarse rhonchi at the bases that clear with cough and on your heart exam your heart is a nice regular rate and rhythm i do n't appreciate any murmur or or rub so what does all of that mean teresa so all of that means is that yes you're showing signs of what we call an upper respiratory infection and i'm concerned that you might have some strep in the back of your throat based on the findings so let's just talk a little bit about my assessment and plan for you okay so for your first problem of your sore throat i'm gon na go ahead and have the medical assistant come in and swab you for a rapid strep test and if that's positive i wan na go ahead and place you on or prescribe amoxicillin five hundred milligrams three times a day for ten days and i'm gon na give you some lidocaine swish and swallow so that will help with some of the pain and you can take some ibuprofen as needed which will also help with the pain and some of that fever okay i do want you to go ahead and continue to to hydrate as much as possible what kind of questions do you have about that
[patient] no that sounds good i just wanted to be sure i was okay because of the little kids
[doctor] sure now for your next problem of your hypertension i wan na go ahead and order a lipid panel on you and i think i do wan na increase i do wan na increase the lisinopril to forty milligrams once a day just to get your blood pressure under better control and we'll see how you do on the forty milligrams once a day for your third problem of your diabetes let's go ahead and order a hemoglobin a1c and just to make sure that we do n't have to make any adjustments to your metformin how does that sound
[patient] sounds good
[doctor] any questions
[patient] nope that's everything
[doctor] okay bye good to see you i'll be in touch

CHIEF COMPLAINT

Sore throat.

MEDICAL HISTORY

Patient reports history of hypertension and diabetes.

SOCIAL HISTORY

Patient reports working as a cashier in a supermarket. She enjoys drinking wine.

MEDICATIONS

Patient reports taking lisinopril 20 mg daily, multi-vitamin, vitamin D, and metformin 1000 mg twice daily.

REVIEW OF SYSTEMS

Constitutional: Reports fever, chills, and profuse sweating.
HENT: Reports sore throat, dysphagia, tonsil swelling, and congestion.
Gastrointestinal: Denies abdominal symptoms.

VITALS

Temperature: 100.4 degrees F.
Blood pressure: 132/80 mm Hg.
Heart rate: 84 BPM.

PHYSICAL EXAM

Head and Face
- Examination: No pain to palpation of the frontal or maxillary sinuses.

Ears, Nose, Mouth, and Throat
- Examination of Nose: Edema and erythema of the nasal turbinates noted bilaterally with associated clear discharge.
- Examination of Throat: Erythema and edema of the peritonsillar space with exudates present bilaterally. The uvula is midline.

Neck
- General Examination: No thyromegaly, but there is some cervical lymphadenopathy on the right side.

Respiratory
- Auscultation of Lungs: Coarse rhonchi at the bases that clear with cough.

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

RESULTS

Rapid COVID-19 test performed today in office is negative.

ASSESSMENT AND PLAN

1. Sore throat.
- Medical Reasoning: The patient has experienced sore throat, fever, chills, profuse sweating, and difficulty swallowing for 4 days. There is erythema and edema of the peritonsillar space with exudates present bilaterally as well as edema and erythema of her turbinates, bilaterally.
- Patient Education and Counseling: We discussed treatment options today. I have stressed the importance of hydration.
- Medical Treatment: We will perform a rapid strep test today. If she is positive for strep, I will prescribe amoxicillin 500 mg 3 times a day for 10 days. Prescription for lidocaine swish and swallow provided for pain relief. ibuprofen can also be taken for pain and fever relief.

2. Hypertension.
- Medical Reasoning: The patient states her blood pressure fluctuates often. Her blood pressure today in office was 132/80 mm Hg. - Patient Education and Counseling: We discussed treatment options including increasing her lisinopril and diet modifications.
- Medical Treatment: Lipid panel ordered. Prescription for lisinopril 40 mg once a day is also provided.

3. Diabetes.
- Medical Reasoning: The patient’s blood sugar fluctuates between 80 to 90 in the morning to 140 in the evening. She is already at 1000 mg of metformin twice a day, which she does take with meals.
- Patient Education and Counseling: We discussed the importance of achieving a healthy lifestyle and what effects that can have on her diabetes.
- Medical Treatment: I have placed an order a hemoglobin A1c.

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


[doctor] good morning carolyn how are you
[patient] i'm doing alright other than this ankle pain i've been having
[doctor] so i see here that you hurt your right ankle can you tell me what happened
[patient] yeah so yesterday i was going to take out the trash and it was quite icy i thought i was doing okay job and i just slipped and and fell and i'm pretty sure i heard a pop
[doctor] okay and you said this happened yesterday correct
[patient] yeah
[doctor] okay and have you been able to walk on it at all
[patient] no i was so initially when i first fell i was unable to walk at on it at all i had a friend that was visiting and so she heard me fall so she helped me inside now today i have been able to put a little bit more weight on it but i'm still limping
[doctor] okay and then what have you been doing for your foot or ankle pain since that happened
[patient] so i like iced it last night and kept it elevated and i also took some ibuprofen last night and this morning before coming in today
[doctor] okay and can you rate your pain for me
[patient] i would say right now it's like a four out of ten
[doctor] okay and does the ibuprofen help with that pain
[patient] it does it does help with the pain
[doctor] okay and when you take your ibuprofen what can you what's your pain level then
[patient] so this so what did i just say four
[doctor] yes ma'am
[patient] four out of ten so four out of ten is with ibuprofen
[doctor] it's with ibuprofen okay what's your pain level without then
[patient] i would say probably a six
[doctor] okay
[patient] i'm sorry it's a six out of ten without ibuprofen and it goes down to like a one with ibuprofen
[doctor] okay alright that that sounds good have you ever injured that foot and ankle before
[patient] you know i've had a lot of injuries to my ankle but i've never hurt this ankle before i just realized an error
[doctor] okay you know and i see here that you have a history of playing sports looks like you played soccer in college and then played a little bit of a inner marrow soccer now
[patient] yeah
[doctor] i'm i'm guessing you probably have n't been able to do that since you hurt your ankle
[patient] no i have not been
[doctor] so did you hear about the new major league soccer stadium and team that's coming to town they opened in the this year actually they built the stadium have you been down there yet
[patient] no i have to get there
[doctor] yeah we are all excited it's going to be a good time well have you experienced any numbness or tingling in that right foot
[patient] no
[doctor] okay so if it's okay with you i would like to do a quick physical exam your vitals look good and everything there looks okay now i'm gon na do a focused exam on your right ankle i do appreciate some ecchymosis or bruising over the lateral malleolus malleolus associated with some edema or swelling of that area you are positive for tenderness to palpation of the anterior lateral soft tissue and now i do n't appreciate any laxity on anterior drawer and inversion stress there is no bony tenderness on palpation to that foot or ankle area now on neurovascular exam of your right foot you have brisk capillary refill of less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch and all of that is consistent with what's present on your left side as well so i did review the results of your of your x-ray the x-ray of your right ankle showed no fracture which is a good thing so now let me talk to you a little bit about my assessment and plan so for the first problem of right ankle pain your symptoms are consistent with a right ankle sprain or i'm sorry right ankle sprain of your lateral ligament complex more specifically your anterior talofibular ligament now this ligament's on the outside of your ankle ankle which got stretched when you fell the best treatment at this time for your sprain is to keep your leg elevated when you're seated and let's continue to ice okay you're gon na be given an air cast which is gon na help stabilize that ankle and i'm also going to prescribe some crutches because i want you to stay off that leg and start walking on it stay off your leg for now and then in a couple of days start walking on it as tolerated do you have any questions or concerns for me
[patient] so how long do you think it'll take to heal
[doctor] so your symptoms should significantly improve over a few weeks but i'd like to follow up with you and see how you're doing let's say i'll see you again in fourteen days now i do want you to go ahead and continue to take nsaids or ibuprofen as needed to help with any pain and that's also gon na help reduce that inflammation and swelling okay
[patient] okay
[doctor] alright i will see you again in two weeks carolyn
[patient] great thank you
[doctor] you're welcome

CHIEF COMPLAINT

Right ankle pain.

HISTORY OF PRESENT ILLNESS

Carolyn Jones is a pleasant 38-year-old female who presents to the clinic today for evaluation of right ankle pain.

The patient sustained an injury to her right ankle when she slipped and fell on ice while taking her garbage out yesterday. This was her first right ankle injury. She believes she heard a pop at the time, but denies any associated numbness or tingling. Initially, she was unable to bear weight on the ankle and required help getting inside; however, she is now able to slightly bear weight but ambulates with an antalgic gait. Ice, elevation, and ibuprofen have been helpful at reducing her pain. She rates her current pain as 4/10, her pain without medication as 6/10, and her pain with medication as 1/10.

Of note, the patient participates in an intramural soccer league but has not been able to play since this injury.

MEDICAL HISTORY

The patient reports that she has had several ankle injuries in the past. This is her first right ankle injury.

SOCIAL HISTORY

The patient reports that she has a history of playing sports. She played soccer in college and is now in an intramural soccer league.

MEDICATIONS

The patient reports that she has been taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right ankle pain.
Neurological: Denies right ankle numbness or tingling.

VITALS

Normal

PHYSICAL EXAM

GAIT: antalgic gait
CV: Brisk capillary refill to less than 3 seconds. Strong dorsalis pedis pulse.
NEURO: Sensation in the right ankle is intact to light touch distally.
MSK: Examination of the right ankle: Ecchymosis over the lateral malleolus associated with trace edema in that area. Tenderness to palpation over the anterolateral soft tissue. No laxity on anterior drawer testing or inversion stress testing. No bony tenderness on palpation of the foot or ankle area. Findings are consistent bilaterally.

RESULTS

X-ray images of the right ankle were obtained and reviewed today. These reveal no evidence of fracture.

ASSESSMENT

Lateral ligament complex sprain, Right ankle.

PLAN

After reviewing the patient's examination and radiographic findings today, her symptoms are consistent with a right ankle sprain of the lateral ligament complex, more specifically the anterior talofibular ligament. We had a lengthy discussion regarding the nature of this injury and the course of treatment. I advised her to keep her leg elevated when she is seated and continue to ice her ankle. She should also continue taking ibuprofen as-needed for pain and inflammation management. She will be placed in an Aircast to help stabilize her ankle, and I am going to order crutches so she can remain non-weight-bearing for the next couple of days. At that point, she can start bearing weight on the ankle as tolerated.

INSTRUCTIONS

The patient will follow up in 2 weeks.


[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] good morning julie how are you doing this morning
[patient] i've been better my primary care doctor wanted me to see you because of this this knee pain that i've been having for about six months now
[doctor] okay and do you remember what caused the pain initially
[patient] honestly i do n't i ca n't think of anytime if i fell or like i i've really been trying to think and i ca n't really think of any specific event
[doctor] okay now it it says here that it's in both knees is that correct
[patient] yes both my knees
[doctor] okay it kinda try let's let's try describing the pain for me please
[patient] yeah it's kind of feels like it's like right behind my kneecaps
[doctor] okay
[patient] and it's like a deep achy pain
[doctor] a deep achy pain okay what kind of activities makes the pain feel worse
[patient] let's see so anytime so if i'm sitting at my desk and i get up i have a lot of pain so anytime from like standing up from sitting for a while or even going up and down the stairs
[doctor] okay so you work from home
[patient] i do
[doctor] okay okay so there is a lot of desk setting at home is your office upstairs or is it i mean do you have to go up or downstairs to get to it
[patient] no well first thing in the morning but otherwise it's downstairs
[doctor] okay okay how do you like working from home
[patient] you know it has it's plus and minuses
[doctor] okay
[patient] i like it though my i like my commute
[doctor] yeah
[patient] i love it
[doctor] and the parking i'm sure the parking is
[patient] and the parking is great
[doctor] yeah i you know if i could do telehealth visits all day long i would be totally happy with that yeah and just set it home and do those so you mentioned is there anything that makes that pain feel better
[patient] usually after like if i feel that pain and then i just it does get better
[doctor] okay now you mentioned earlier that you tried some things in the past what have what are they and did they work at all
[patient] yeah i've done some ibuprofen or aleve sometimes some tylenol and that does help
[doctor] okay
[patient] it takes the edge off
[doctor] okay but you're never really pain free is that what i hear you saying
[patient] not really unless i'm like really just resting which i hate to do but otherwise any type of movement especially from sitting it causes pain
[doctor] okay so are you active other than going up and down the steps to your office
[patient] very i'm a big runner i love to run i run about five to six miles a day but with this knee with with these knee pain that i've been having it's i barely can even do half a mile
[doctor] yeah you know what that's that's i am a biker and i know that once you get that into your you know you have loved doing that activity it's so frustrating when you ca n't it's almost like a it's almost like a dry it almost becomes a drug when you get up
[patient] exactly
[doctor] yeah
[patient] it's
[doctor] okay so have you noticed any redness or swelling in your knees
[patient] no
[doctor] okay and have you ever injured your knees before
[patient] you know despite how active i am i you know i've never
[doctor] okay
[patient] injured or broken a bone
[doctor] okay great so let's go ahead and do a i just wan na take a look here i reviewed your vitals and overall they look good your blood pressure is one twenty over seventy your your heart rate is sixty and your respiratory rate is fourteen those are all phenomenal numbers as i listened to your heart it is at a regular and a slower rate but i do n't hear any extra sounds so there is no murmurs as we go through that now on musculoskeletal exam you have a normal gait i watched you you know kinda walk in here this morning your strength i just wan na check it when i go ahead and i want you to move your leg okay your muscle strength is is good you do have a three out of five for abduction of your legs bilaterally and that's you know kinda bringing your legs in the remainder of your muscle strength for your lower extremities is a five out of five now let me focus specifically on your knee examination i do n't see any redness or ecchymosis or warmth of the skin and those are big words you know i do n't see any bruising or or that redness there is no effusion that's just like a fluid underneath the knee i do n't appreciate that any at all you do seem to have some tenderness when i palpate and you do have a positive patellar grind test when you stood up i could feel that as we went through there you did say you had that knee pain with squatting but your lachman your anterior and posterior drawer and mcmurray test are all negative bilaterally neurologically and your your your lower extremities your patella and your achilles reflex are symmetrical and that's good so i did review the x-rays of both your knees which shows no fractures or osteoarthritis so based on what you told me and reviewing the mri that you had done before you came in your symptoms are consistent with patellofemoral pain syndrome and this is a really common condition that we see that causes knee knee pain especially in really active young people that's probably why i do n't get it when i'm riding my bike forever and ever now this condition has to do with the way your kneecap moves across along the groove of your thigh bone your femur so for pain i want you to continue to take the ibuprofen or any other anti-inflammatories you know aleve or any of those as you need it to help with the pain now i am going to recommend physical therapy well they will show you a number of lower extremity exercises this is probably one of the best things that you can do and this will help increase your lower extremity strength your mobility and correct any incorrect running mechanics that you might have do you have any questions for me
[patient] so will i be able to run again
[doctor] absolutely my goal is to get you out there and maybe we can cross pads on the the bike trail some day you are gon na have to take it a little bit easy for now but we are gon na get you back and once we do that i think you will be really pleased is there anything else
[patient] no i think that's it
[doctor] okay have a great day
[patient] okay you too
[doctor] thank you
[patient] bye

CHIEF COMPLAINT

Bilateral knee pain.

SOCIAL HISTORY

The patient is an avid runner. She also works from home.

REVIEW OF SYSTEMS

Musculoskeletal: Reports bilateral knee pain. Denies knee swelling.
Skin: Denies redness.

VITALS

Blood pressure: 120/70 mmHg
Heart rate: 60 bpm
Respirations: 14

PHYSICAL EXAM

Neurological
- Orientation: Normal gait. Patellar and Achilles reflexes are symmetrical.

Cardiovascular
- Auscultation of Heart: Regular, slower rate. No murmurs.

Gastrointestinal
- Examination of Abdomen: No masses or tenderness.
- Auscultation: Bowel sounds normal in all 4 quadrants.

Musculoskeletal
- Examination: No clubbing, cyanosis, or edema. Normal gait. 3/5 abduction strength of the bilateral lower extremities. Otherwise, 5/5 strength in the bilateral lower extremities.
- Bilateral knees: No erythema, ecchymosis, or warmth. No effusion. Tender to palpation. Positive patellar grind test. Lachman, anterior and posterior drawer, and McMurray test are all negative bilaterally.

RESULTS

X-ray of the bilateral knees are reviewed and reveal no fractures or osteoarthritis.

ASSESSMENT AND PLAN

1. Patellofemoral pain syndrome, bilateral.
- Medical Reasoning: After reviewing her x-ray, previous MRI, and exam findings, her symptoms are consistent with patellofemoral pain syndrome.
- Patient Education and Counseling: We discussed the nature of this condition in detail. I encouraged the patient to be conservative with her physical activity for now.
- Medical Treatment: Continue with over-the-counter NSAIDs for pain relief We are going to refer her to physical therapy to help strengthen her lower extremities, increase mobility, and demonstrate proper running mechanics.

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


[doctor] hi abigail how are you today
[patient] hello hi nice to meet you i'm i'm doing okay
[doctor] good i'm doctor sanchez and i'm gon na go ahead and take a look i saw with your notes that you've been having some knee pain yes that's that's true you know it's been going on for a while i like to run i do jogs i sign up for the 5k tack you know sometimes the marathon and i have n't been doing longer distances because
[patient] when i'm running i my right knee here it just starts to ache and it's it's just to the point where i need your opinion
[doctor] okay okay what have you done for it so far what makes it better what makes it worse
[patient] well it used to be that when i run it ache and then i put ice on it and then it would be okay so i do ice and ibuprofen
[doctor] okay okay and did you see anybody for this before coming into the office here
[patient] yeah i doctor wood is my primary care provider and i talked to him about it actually over the years and this last visit he said he referred me to you
[doctor] okay okay good so ice and rest makes it feel better running and and activity makes it hurt a little bit more is that correct
[patient] yeah that's right
[doctor] okay do you have any family history of arthritis or any of those type of immune diseases
[patient] i'm trying to think no i do n't think so no
[doctor] okay and do you get is it is this primarily worse in the morning or does it is it just there all the time when it comes on
[patient] it actually is worse towards the end of the day
[doctor] okay
[patient] once i'm on my feet all day it starts to ache towards the afternoon
[doctor] okay so let's go ahead and i want to do a quick examination here your blood pressure and was one twenty over sixty that's phenomenal your heart rate was fifty eight and you can tell that you're a runner with that that level of a heart rate and your respirations were fourteen so all of that looked very good there was no fever when you came in when i'm gon na just quickly listen to your heart and lungs okay those those sound good but let me get let's focus here on your lower extremities i'm i'm gon na look at your your left knee first when i move your left knee do you get any type of pain or is it just feel like normal and it's always your pain's always isolated to the right
[patient] that feels that feels normal
[doctor] okay okay so let me i just want you to back up here in the stretcher a little bit more and i'm just gon na do some movement of your knee any okay so i want you to push your leg out against my hand does that hurt
[patient] no
[doctor] okay and if you pull back does that hurt a little bit
[patient] no
[doctor] okay and i'm gon na move it around so when i look at the knee there is no redness there's no swelling i can appreciate a a small amount of effusion and that means that there's a little bit of fluid under the knee or in that knee's joint space and there is there is several reasons that could be now when i push on your knee does it hurt more on the inside or does it hurt more on the outside here
[patient] the the right knee here hurts on the outside
[doctor] okay okay and you've got a good pedal pulse so you know you can feel that and when i touch your feet you do n't have any numbness or tingling or anything like that
[patient] no uh uh
[doctor] okay well so what i want to tell you is that i think you have a knee sprain from overuse and we see that sometimes in runners now unfortunately you're gon na have to take some a little bit of time off of of active running but i do n't think it will be that long until we can get you up and running again now i reviewed the x-rays that we did when you first came into the office here this morning and the joint spaces of that right knee are are well maintained i do n't see any evidence of any fracture and when compared to the left knee everything looks good so i do n't even see any signs of any arthritis that i would've been suspecting i would like you to stay on two tylenol five hundred milligrams and two ibuprofen two hundred milligram tablets and i want you to take that three times a day and that's gon na help with both the pain and the inflammation i'm also gon na order some physical therapy for your your right knee and that physical therapy will help strengthen the lower extremities and make it give you a little bit of a balance and some they'll be able to recommend good running exercises for you i do wan na follow up with you in two weeks and see if we're getting better so let's no running for two weeks and if we're we're improving then we'll move on and probably start adding some additional activity does that sound like a plan
[patient] yeah that does i i was curious so i will lay off the running for now can i you know lift weights and do like my squats and and those type of exercises at the gym
[doctor] yeah absolutely and and those are good exercises but i'd like you to get that first physical therapy appointment in and they'll be able to talk with you on what the best exercises are for you to do
[patient] okay got it
[doctor] any questions
[patient] hmmm no i do n't think so
[doctor] okay thank you abigail and i'd like i said stop out at the desk and we'll make an appointment for two weeks
[patient] okay thanks doctor
[doctor] thank you

CHIEF COMPLAINT

Right knee pain.

SOCIAL HISTORY

Patient reports she is an avid runner who enjoys participating in marathons.

FAMILY HISTORY

Patient denies any known family history of arthritis or other immune disease.

REVIEW OF SYSTEMS

Constitutional: Denies fever.
Musculoskeletal: Reports right knee pain.

VITALS

Blood pressure: 120/60 mmHg
Heart rate: 58 bpm
Respiration: 14
No fever.

PHYSICAL EXAM

Respiratory
- Assessment of Respiratory Effort: Normal respiratory effort.

Cardiovascular
- Examination: Normal pedal pulses in right knee.
- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.

Musculoskeletal
- Examination: No clubbing, cyanosis, or edema.
- Right knee: No pain with movement. No pain with strength testing. No erythema or edema. Small effusion. Tender to palpation over the lateral aspect of the knee.

RESULTS

X-rays of the right knee were obtained and reviewed in office today. These reveal well-maintained joint spaces. There is no evidence of any fracture or arthritis.

ASSESSMENT AND PLAN

1. Right knee sprain.
- Medical Reasoning: The patient is an avid runner and her symptoms appear to be the result of overuse.
- Patient Education and Counseling: We discussed the nature of her diagnosis, as well as her x-ray results, in detail. I advised her that this is a common issue for runners and encouraged her to continue her strength training exercises.
- Medical Treatment: She will take Tylenol 500 mg, 2 tablets, and ibuprofen 200 mg, 2 tablets, 3 times daily to reduce her pain and inflammation. We will also refer her to physical therapy to help strengthen her lower extremities, work on her balance, and demonstrate proper running exercises. She should avoid running for the next 2 weeks until her follow up visit, at which point we can consider adding some additional activity.

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

INSTRUCTIONS

The patient will follow up in 2 weeks.


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

CHIEF COMPLAINT

New patient evaluation of newly diagnosed ovarian cancer.

FAMILY HISTORY

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

REVIEW OF SYSTEMS

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

PHYSICAL EXAM

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

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

RESULTS

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

ASSESSMENT AND PLAN

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

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


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

CHIEF COMPLAINT

Difficulty urinating.

MEDICAL HISTORY

Patient reports history of coronary artery disease and diabetes.

SURGICAL HISTORY

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

SOCIAL HISTORY

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

REVIEW OF SYSTEMS

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

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally.

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

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

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

ASSESSMENT AND PLAN

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

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

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

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

INSTRUCTIONS

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


[doctor] alright brittany so i see that you are experiencing some right foot pain could you tell me what happened
[patient] yeah well i was playing tennis and i was trying to you know volley the ball
[doctor] mm-hmm
[patient] it was like a double game and i was trying to volley the ball and i got in front of another player and actually ended up falling on top of my foot
[doctor] alright
[patient] and then yeah it kinda hurt i quickly then twisted my myself around her because i was trying to catch myself but then i started to feel some pain in my foot
[doctor] mm-hmm okay have you ever injured that foot before
[patient] yeah no sorry i injured my other foot before not this foot
[doctor] okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing
[patient] yeah that's fine
[doctor] alright were you able to continue playing
[patient] no i had to stop i actually it was like i had to be held from the field because i could n't put weight on my foot
[doctor] i'm sorry okay so what have you been doing for the pain since then
[patient] i wrapped it after a the game they had some ace wraps in their clubhouse and so i wrapped it up and then i iced it last night and i just kept it up on a pillow and then i took some ibuprofen
[doctor] okay could you one more time when did this injury happen
[patient] this happened about couple days ago
[doctor] okay so did you say whether does the ibuprofen help at all
[patient] yeah it helps a little bit but then you know it it you know after a while it wears out
[doctor] okay and then have you experienced any numb numbness or tingling
[patient] no no numbness
[doctor] okay alright any loss in sensation
[patient] no i mean i i can still feel like i can still feel my foot
[doctor] okay alright that's good to hear so you were playing tennis is that what you normally do to work out
[patient] i do i'm trying to learn but i can not afford tennis less lessons so me and my friends just hit the balls back and forth i do sleep
[doctor] i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah
[patient] that scares me
[doctor] it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay
[patient] okay
[doctor] alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt
[patient] no uh uh
[doctor] okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions
[patient] yeah do i have to do the surgery
[doctor] so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with
[patient] i just hate that word surgery doc
[doctor] i know
[patient] you know it scares me every time i mean especially with my foot i want to be able to walk again and so i just get really worried i mean how long is the procedure usually too
[doctor] so it's actually
[patient] have to be in the hospital
[doctor] no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed
[patient] i'm right handed
[doctor] yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what
[patient] i mean
[doctor] uh uh
[patient] does that mean i'm out for the rest of the season i mean i wan na be able to get back and play again i really am i'm getting a little better so i
[doctor] mm-hmm
[patient] i really wan na keep on playing my tennis with my friends but
[doctor] yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there
[patient] i suppose so
[doctor] yeah
[patient] okay
[doctor] alright
[patient] thank you
[doctor] no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay
[patient] okay
[doctor] alright
[patient] good
[doctor] thank you
[patient] thank you

HISTORY OF PRESENT ILLNESS

Brittany Edwards is a 76-year-old female, right-hand-dominant, female who presents to the clinic today for the evaluation of right foot pain. The onset of her pain began 2 days ago, when she was playing tennis and was trying to volley the ball when she got in front of another player and fell on the dorsal aspect of her right foot. She states that she quickly twisted her foot because she was trying to catch herself. The patient reports that she was unable to continue playing secondary to the pain. She states that she wrapped her foot after the game and iced it last night. The patient adds that she kept her foot up on a pillow and took ibuprofen for pain. She denies any numbness. The patient denies any loss of sensation.

The patient has a history of a left leg injury.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right foot pain.
Neurological: Denies numbness in the right foot.

PHYSICAL EXAM

SKIN: Warm
NEURO: Normal sensation.
MSK:
Examination of the right foot: Bruising of the plantar and dorsal aspects of the foot. Associated swelling. Tenderness to palpation of the midfoot. Positive piano key test of the 1st and 2nd metatarsals. Warm to touch. Neurovascular intact distally. Capillary refill is less than 3 seconds. Strong dorsalis pedis pulse.
Examination of the left foot: Brisk capillary refill to all digits and light touch intact.

RESULTS

3 views of the right foot were taken. These reveal subtle dorsal displacement of the base of the 2nd metatarsal with a 3 mm separation of the 1st and 2nd metatarsal bases. There is the presence of a bony fragment in the Lisfranc joint space.

ASSESSMENT

Right foot pain, consistent with a Lisfranc fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her x-rays revealed a Lisfranc fracture. We discussed treatment options for this and I have recommended that we proceed with surgical intervention. The plan is to proceed with a right foot ORIF and all indicated procedures. We went over the risk, benefits, and alternatives of the surgery. The risk include but not limited to continued pain, swelling, damage to surrounding tissue including nerves and blood vessels, numbness that could be permanent, infection, nonunion, malunion, failure of hardware, and need for further surgery. There is always a risk of amputation, heart attack, stroke, blood clots, pulmonary embolism, and death. There is a possibility of chronic pain and the inability to get back to the previous level of function. The patient wishes to proceed with the operation and she will follow up with me on the day of surgery. In the meantime, I have recommended that the patient attend formal physical therapy to strengthen her right foot.