[doctor] patrick allen . date of birth : 7/7/1977 . new patient visit . past medical history includes gerd , anxiety , depression . here for chronic abdominal pain . he had an abdominal ct on 1/23/2020 . impression is a normal ct of the ab- abdomen .
[doctor] hello , are you mr. allen ?
[patient] yes , i am .
[doctor] hi . my name is dr. edwards . nice to meet you .
[patient] nice to meet you .
[doctor] welcome to the gi specialty clinic .
[patient] thank you .
[doctor] did you have any problems finding us ?
[patient] no , i've been here with my sister once before .
[doctor] good . so how can i help you today ? uh , the referral i have is for abdominal pain and diarrhea .
[patient] right . so i've had ... i've been having this pain right here in my stomach , like right around here .
[doctor] so in the area of your mid abdomen , just below the belly button ?
[patient] correct . i've had the pain on and off for about two years . i finally went to the er and a ... a few months ago and they did a ct scan .
[doctor] i saw that .
[patient] yeah . they said they did n't really see anything on the scan .
[doctor] yes , i agree . it looked normal .
[patient] the problem is i'm either constipated or have explosive diarrhea .
[doctor] is the pain there all the time ?
[patient] it's a nagging feeling and it just depends . sometimes it bothers me , sometimes it does n't .
[doctor] has this been the case over the past two years as well ?
[patient] more recently in the past couple months , at least with the constipation and diarrhea .
[doctor] and before that , how are your bowel movements ?
[patient] they were normal .
[doctor] uh , okay . so any blood in your stool ?
[patient] nope .
[doctor] do you feel like you have more constipation or diarrhea ?
[patient] probably more constipation .
[doctor] okay , so when you're constipated , do you not have a bowel movement or is the stool hard ?
[patient] i usually do n't go , but when i do , it's hard .
[doctor] and how often do you have a bowel movement when you are constipated ?
[patient] about three to four times a week . it's like when i need to go to the bathroom , if i can massage it , it feels like it's moving some and i can eventually go .
[doctor] okay . and when you have a bowel movement , does the pain change ?
[patient] yeah , it gets a little better .
[doctor] and are you eating and drinking okay ? any nausea or vomiting , heartburn or indigestion ?
[patient] none of that .
[doctor] okay . so tell me about the diarrhea , how often do you get it ?
[patient] it kinda just depends on what i eat . i think i have a very sensitive stomach . if i eat pasta with a creamy sauce , i'm probably gon na have diarrhea .
[doctor] okay . and it does n't happen for multiple days in a row or is it just one time ?
[patient] it's usually just one time and then it's over .
[doctor] and how's your weight been ? any fluctuation ?
[patient] nice and pretty stable , although i could stand to lose about 25 pounds .
[doctor] okay . and is there any family history of gi issues that you know of ?
[patient] not that i can think of . well , actually my sister does have problems with her stomach too . she has irritable bowel syndrome and that is kind of what i always thought i had even thought i've never been diagnosed with it .
[doctor] okay . and is there any family history of gi cancer or liver disease ?
[patient] nope .
[doctor] have you ever had any surgeries on your abdomen ?
[patient] i've never had any surgery .
[doctor] okay , so your gallbladder , appendix , all those are still intact ?
[patient] yup .
[doctor] and have you ever had a colonoscopy ?
[patient] no . i thought that happen when you turn 50 .
[doctor] well , that's for colon cancer screening , but there are other reasons to have a colonoscopy , like unexplained abdominal pain and changes in bowel habits .
[patient] okay .
[doctor] well , come have a seat here and lay back so i can examine you .
[patient] okay .
[doctor] i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants .
[patient] what does that mean ? is everything okay ?
[doctor] it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working .
[patient] okay , good .
[doctor] so now , i'm going to push on your upper and lower abdomen . let me know if you have any pain .
[patient] it hurts a little when you push right there on the left side , near my belly button .
[doctor] okay . i do feel stool in your lower colon , which would coincide with constipation , but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ?
[patient] yes , i have a physical about four months ago and they ... i had blood drawn then .
[doctor] okay . and did your primary care physician say anything about the lab results ?
[patient] he said i had some very slightly elevated liver enzymes , but we would recheck them in about six months .
[doctor] and you remember what enzymes were elevated , alt , ast , alp ?
[patient] he said the alt and the ast were elevated .
[doctor] and do you take any medications , either prescription or over-the-counter ?
[patient] i take crestor and olmesartan daily and then tylenol for occasion- occasional pain .
[doctor] and how frequently do you take the tylenol ?
[patient] hardly ever . maybe once a month .
[doctor] and do you consume alcohol ?
[patient] uh , yes , but only a couple of beers after working in the yard on saturdays .
[doctor] okay . and no previous history of heavy alcohol or drug use ?
[patient] nope .
[doctor] and have you had any recent issues with excessive bruising or bleeding ?
[patient] nope .
[doctor] and how about any issues with your ankles or feet swelling ?
[patient] no .
[doctor] okay . i'm gon na take a look at your eyes and skin . i do n't see any jaundice .
[patient] what would cause that ?
[doctor] issues with your liver . let me take a quick listen to your heart and lungs .
[patient] okay .
[doctor] lungs are clear , bilateral heart sounds are normal , no murmurs , gallops , or rubs noted .
[patient] that's good .
[doctor] yes . the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly .
[patient] what's that ?
[doctor] increase stool burden means that there's a lot of stool sitting in your colon .
[patient] and that's the constipation , right ? but what about the other thing ?
[doctor] the hepatomegaly means the liver is enlarged .
[patient] but you said mine was slightly enlarged ?
[doctor] correct .
[patient] so what does that mean ?
[doctor] well , let's talk about what we found and then some possible next steps if you're in agreement .
[patient] okay .
[doctor] so as i said , the hepatomegaly means your liver is enlarged .
[patient] could that be why my stomach is hurting and i'm having issues with the constipation and diarrhea ?
[doctor] no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that .
[patient] so what about my liver ? why is it enlarged ?
[doctor] well , there are many reasons why people can have an elevated liver enzymes and also enlarged liver . some possible causes are certain medications that can be toxic to liver , alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease .
[patient] so what do i need to do ?
[doctor] well , i think since it's been about four months since your blood work was done , we should check your liver enzymes in addition to a few other labs .
[patient] okay . and then what ?
[doctor] we will get those drawn today and then depending upon the results you may need an ultrasound of your liver . i think we need to talk about your medications too .
[patient] which medications ?
[doctor] crestor , how long have you been taking that ?
[patient] about 18 months .
[doctor] okay . well , crestor is one of the medications that can cause liver toxicity so it may be a good idea to discuss other alternatives .
[patient] should i talk to my primary care or can you change it ?
[doctor] i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol .
[patient] okay . i'll call him this afternoon .
[doctor] great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that .
[patient] okay . when do you think i'll be able to get the ultrasound done ?
[doctor] hopefully , within the next two weeks . you will receive a call from the radiology scheduling this afternoon to get it set up .
[patient] okay . and then what happens ?
[doctor] when i get the results from the test , i will contact you . and depending upon what we find , we'll come up with our next steps .
[patient] and when should i see you again ?
[doctor] uh , let's schedule an appointment when you check out to return in four weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver .
[patient] okay . is there anything else i can do to help with these issues ?
[doctor] definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day in addition to taking the fiber supplement to help with your constipation . and be mindful of eating foods that you were sensitive to so you can avoid the bouts of diarrhea .
[patient] okay . and i'll talk to my primary care about my crestor .
[doctor] excellent . and do you have any other questions for me ?
[patient] i do n't think so .
[doctor] great . so remember when you check out the front desk , schedule follow-up appointment with me for four weeks and then go to the lab to get your blood work drawn .
[patient] okay . sounds good .
[doctor] and expect a call from radiology scheduling about setting up your ultrasound .
[patient] all right . thanks , dr. edwards .
[doctor] thank you , mr. allen .

CHIEF COMPLAINT

Abdominal pain and diarrhea.

HISTORY OF PRESENT ILLNESS

Patrick Allen is a 42-year-old male who presents for a new patient visit for chronic abdominal pain, constipation, and diarrhea.

Mr. Allen reports experiencing intermittent mid-abdominal pain for approximately 2 years. The pain is localized just inferior to the umbilicus and he describes it as a “nagging feeling” when it is present. The pain sometimes improves following a bowel movement. Unfortunately, Mr. Allen reports that the pain has been present more often in the past 2 months. In 01/2020, the patient presented to the emergency room due to the pain and underwent a CT scan.

In addition to the abdominal pain, Mr. Allen complains of constipation and episodic severe diarrhea for the past 2 months; however, he estimates that the constipation is more frequent than the diarrhea. When he is constipated, he has a bowel movement 3-4 times a week and the stools are hard. Regarding his diarrhea, he has noticed that it seems to be associated with certain foods. In particular, he notes that pasta with a creamy sauce is likely to prompt an episode of diarrhea. When this occurs, he usually has just 1 bowel movement of diarrhea and then it resolves. The patient states that, prior to 2 months ago, his bowel movements were normal. Mr. Allen notes that massaging his abdomen has sometimes been helpful in producing a bowel movement.

The patient’s last physical was 4 months ago, and he confirms that he did have bloodwork that day. Mr. Allen reports that his primary care provider notified him that his AST and ALT were mildly elevated and advised that they would need to recheck his liver enzymes in 6 months. The patient’s medication list includes Crestor and olmesartan daily and he estimates that he has been taking the Crestor for approximately 18 months. He also takes Tylenol as needed for pain, approximately once a month. The patient states that he drinks 2 beers once a week and denies a history of heavy alcohol or drug use. He also denies excessive bruising or bleeding and any lower extremity edema.

The patient denies blood in his stools, nausea, vomiting, heartburn, and indigestion. He confirms that he is eating and drinking normally, and his weight has been stable. He does acknowledge that he would like to lose 25 pounds, however. He has no family history of gastrointestinal cancer or liver disease; however, his sister has irritable bowel syndrome (IBS). The patient has not had any prior abdominal surgeries and he has never had a colonoscopy.

PHYSICAL EXAM

Respiratory
Lungs clear to auscultation bilaterally.

Cardiovascular
No murmurs, gallops, or rubs.

Abdomen
Normoactive bowel sounds in all 4 quadrants. There is mild left periumbilical tenderness to palpation, mild hepatomegaly, and increased stool burden in colon.

RESULTS

CT of Abdomen, 01/23/2020.
Impression: Normal CT of abdomen.

ASSESSMENT

• Constipation
• Mild hepatomegaly

PLAN

Patrick Allen is a 42-year-old male who presents for a new patient visit for chronic abdominal pain, constipation, and diarrhea. The most likely etiology of his abdominal pain is constipation given his history, exam with increased stool burden, and normal abdominal CT. Mild hepatomegaly was also noted on exam today and the patient reportedly had elevated liver enzymes on labs with his primary care provider 4 months ago. The patient is currently on Crestor which may be contributing to his elevated liver enzymes. We discussed findings, diagnosis, and next steps at length.

Constipation
• Start daily fiber supplement and increase water consumption to at least 48 ounces daily to help with bowel regularity.
• Avoid trigger foods that may cause episodes of diarrhea.

Mild Hepatomegaly
• Repeat liver enzyme labs today.
• Schedule a liver ultrasound pending lab results.
• Encouraged to cease alcohol consumption.
• Patient to contact his PCP to discuss alternative medications.

INSTRUCTIONS

Return to clinic in 4 weeks.


[doctor] next patient is sophia jackson , mrnr472348 . she's a 57 year old female who is here for a surgical consult . her dermatologist referred her . she biopsied a 0.7 millimeter lesion which was located on right inferior back . pathology came back as melanoma .
[doctor] mrs. jackson , it's good to meet you .
[patient] likewise , wish it were under better circumstances .
[doctor] yeah , i hear your dermatologist sent you to me 'cause she found a melanoma ?
[patient] yes , that's what the biopsy said .
[doctor] okay and when did you first notice the spot ?
[patient] my mom noticed it when i was visiting her last month .
[doctor] i see . and so you went to the dermatologist on april 10th to get it checked out , right ?
[patient] yes , i wanted to be extra cautious because skin cancer does run in my family .
[doctor] well i'm really glad you took it seriously and got it checked . who in your family has had skin cancer , and do you know if it was melanoma or was it basal cell or squamous cell ?
[patient] my mom and her sister , i think they both had melanoma .
[doctor] okay . do you have any other types of cancer in the family , like breast or ovarian ?
[patient] my grandfather had pancreatic cancer .
[doctor] okay , and was that your mom or dad's father ?
[patient] mother's .
[doctor] okay . and , um , have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ?
[patient] no , this was the first time i've been to a dermatologist . um , but my primary care doctor looks over all of my moles every year at my physical and has n't said , um , he's concerned about any of 'em before .
[doctor] good- good . uh , let's go over your medical history from your chart . i have that you're not taking any medications and do n't have any health problems listed , but that you're allergic to augmentin , is that right ?
[patient] yes , that's correct .
[doctor] okay , and for social history can you tell me what you do for work ?
[patient] i own an auto repair shop .
[doctor] okay and have you ever been a smoker ?
[patient] yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying .
[doctor] i'm glad you're trying to quit . uh , what about your surgical history , have you had any surgeries ?
[patient] i had gall bladder and appendix .
[doctor] okay , great , we can get your chart up to date now , thank you . and other than the melanoma , how has your health been , any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ?
[patient] no , i've been feelin' great .
[doctor] good . well let me take a look at your back here where they did the biopsy if you do n't mind .
[patient] sure .
[doctor] okay , i'm gon na describe it in medical jargon what i'm seeing here , so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ?
[patient] okay , that's fine .
[doctor] all right , so on the right inferior back there's a one centimeter shave biopsy site , including all of the dermis with no residual pigmentation . there's no intrinsic or satellite lesions , no other suspicious moles , no axillary , cervical , or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin , but it's nontender , otherwise normal exam .
[doctor] okay , you can sit up . um , so what i was saying there is that i see your biopsy site , but i do n't see any other s- , um , skin lumps or bumps that look suspicious . uh , i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing , um , and , you know , make sure it's nothing that we need to worry about . uh , the reason we're being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further .
[patient] okay , i should n't worry too much then ?
[doctor] no , i have a low suspicion that it will show anything .
[patient] okay , good .
[doctor] so assuming that the ultrasound is normal , the treatment for you melanoma is to cut out the area where the lesion was . with lesions that are 0.7 millimeters or less , um , and that's what we recommend , and yours was exactly 0.7 millimeters . if it were any bigger , we would have had to do a more complex surgery . but what i recommend for you is what we call a wide local incision , excuse me , excision , meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision .
[patient] okay , that is fine with me , i ca n't see back there anyways .
[doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it , as it heals . um , but since we're , we are n't doing the more complex surgery , i actually do n't need to see you back unless you want to check in with me or have any problems . however , it is very important that you continue to follow up with your dermatologist regularly so she can monitor you . uh , your dermatologist will check that this one does n't come back , but she'll also check for other lesions that look suspicious . uh , unfortunately , since you've had one melanoma , you're at a higher risk of developing another one somewhere else .
[patient] yeah , she did say she wants to see me back .
[doctor] good , and i'm sure she's already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight .
[patient] yeah , she definitely went over that , um , several times with me .
[doctor] good . other than that , i think that's all for me . um , we'll get you set up for the ultrasound , the procedure . do you have any questions for me ?
[patient] um , no i ca n't think of any at this time .
[doctor] okay , my nurse will be in to get you scheduled , so sit tight . it was very good to meet you .
[patient] thank you , nice to meet you as well .
[doctor] please add the following pathology r- , to results . a pathology , shave of right inferior back , malignant melanoma , invasive , superficial spreading . histology , superficial spreading . clark level 4 , breslow thickness 0.7 millimeters , radial growth phase present , vertical growth phase not identified . mitotic features , less than one millimeter squared . ulceration not identified , progression not identified , lymphatic invasion not identified , perineural invasion not identified , microscopic satellitosis not identified . infiltrating , uh , lymphocytes , breast . um , melanocytic nevus not identified . predominant cytology epithelioid , peripheral margin positive , deep margin , uh , negative , stage 1 . also note that i reviewed the dermatologist's photo of the lesion which showed an asymmetric black and brown nevus with central a melanotic component and irregular border .
[doctor] for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a one to two centimeter margin .
[doctor] primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up , according to the national comprehensive cancer network guidelines , was reviewed . we also reviewed the principles of sun avoidance , skin self-examination , and the abcdes of mole surveillance .
[doctor] after discussing the procedure , risk and expected outcomes , and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

CHIEF COMPLAINT

Melanoma.

HISTORY OF PRESENT ILLNESS

Sophia Jackson is a very pleasant 57-year-old female who presents for a surgical consult for melanoma of the right inferior back. She was referred by her dermatologist who biopsied the 0.7 mm lesion on 04/10 and diagnosed the melanoma. The lesion was initially noticed by the patient’s mother when she was visiting her last month. Mrs. Jackson denies a personal history of atypical nevi and reports that she has annual mole checks by her primary care provider at her physicals. She has never seen a dermatologist prior to last month. There is a family history of melanoma in her mother and maternal aunt. The patient reports that she has been in her usual state of health with no unintentional weight changes, headaches, fatigue, nausea, vomiting, or vision changes.

PAST HISTORY

Medical
None reported.

Surgical
Cholecystectomy.
Appendectomy.

SOCIAL HISTORY

Patient owns an auto repair shop.
Current smoker since teens. Actively trying to quit.

FAMILY HISTORY

Mother: melanoma.
Maternal aunt: melanoma.
Maternal grandfather: pancreatic cancer.
No family history of breast or ovarian cancers.

MEDICATIONS

None.

ALLERGIES

Augmentin.

PHYSICAL EXAM

Hematologic/lymphatics: No axillary, cervical, or supraclavicular lymphadenopathy. There is a soft lymph node in the right groin. Nontender.
Skin: On the right inferior back there is a 1 cm shave biopsy site including all of the dermis with no residual pigmentation. There’s no intrinsic or satellite lesions. No other suspicious moles.

RESULTS

Pathology Report.

Pathology: Shave biopsy of right inferior back malignant melanoma, invasive, superficial spreading.
Histology: Superficial spreading.
Clark level: 4.
Breslow thickness: 0.7 mm.
Radial growth phase: present.
Vertical growth phase: not identified.
Mitotic figures: less than 1 mm2.
Ulceration: not identified.
Regression: not identified.
Lymphatic invasion: not identified.
Perineural invasion: not identified.
Microscopic satellitosis: not identified.
Infiltrating lymphocytes: breast.
Melanocytic nevus: not identified.
Predominant cytology: epithelioid.
Peripheral margin: positive.
Deep margin: Negative.
Stage: 1.

I reviewed the dermatologist’s photo of the lesion which showed an asymmetric black and brown nevus with central amelanotic component and irregular border.

ASSESSMENT AND PLAN

The patient presents today with newly diagnosed melanoma. The biopsy revealed an intermediate thickness melanoma. On examination today, there is a right inguinal lymph node with slightly atypical consistency. I recommended an ultrasound to rule out metastatic disease. If the ultrasound is normal, the patient is a candidate for a wide local excision with a 1-2 cm margin. Primary closure should be possible, but skin graft closure may be needed. The relationship between tumor histology and prognosis and treatment was carefully reviewed. The need for follow up according to the National Comprehensive Cancer Network (NCCN) guidelines was reviewed. We also reviewed the principles of sun avoidance, skin self-examination, and the ABCDE’s of mole surveillance. After discussing the procedure, risks, expected outcomes and possible complications, questions were answered, and the patient expressed understanding and did choose to proceed.


[doctor] donna torres , date of birth , 08/01/1980 .
[doctor] hi donna ! how are you ?
[patient] i'm good . how about you ?
[doctor] i'm doing well , thank you . and so , i saw that dr. brown put you on buspar . have you been on that before ?
[patient] no , that's new .
[doctor] okay . how is it working for you ?
[patient] my anxiety is going good now , thankfully . i'm serious , it was brutal in november and december . finally , i was like , " i can not do this . " i have no idea why it happened . dr. ward did put me on singulair , and she did say we need to be careful because singulair can cause anxiety . so i'm not sure if that was the issue or what .
[doctor] mm . okay .
[patient] and it would , um , start usually during the day , at work .
[doctor] i see .
[patient] i mean , i'm fine now .
[doctor] well , that's good , that things have settled . i do wonder if some of what you are dealing with is hormonal , and that's why i was asking . 'cause you were on the progesterone , and i feel like you were having some irritability back then too .
[patient] i did .
[doctor] and that was before we started the progesterone .
[patient] yes .
[doctor] so i know we started it for regulating your periods , but perhaps it helped with this also .
[patient] yeah . and before , in november and december , i noticed that the week before my period , my anxiety would go through the roof . which then , i knew my period was coming . then it turned into my anxiety spiking just at random times .
[doctor] hmm , okay .
[patient] and it seemed like it was for no reason .
[doctor] but november and december you were on the progesterone at that time .
[patient] yes .
[doctor] all right . so not really a link there , all right .
[patient] yeah , i do n't know .
[doctor] yeah , i do n't know either . um , sometimes with the aging process , that can happen too .
[patient] i figured maybe that's what it was .
[doctor] and we did go through the golive in november and december , so that can be pretty stressful also .
[patient] yeah , and at work , that's when i first started to lead the process of delivering the results to patients with covid . in the beginning of the whole pandemic , patients would have to wait nine days before they'd get their results . and then we opened the evaluation centers and the covid clinic . so i think it just took a toll on me .
[doctor] yeah , i can absolutely see that .
[patient] yeah , and then i was feeling selfish because i was n't even on the front lines . i mean , i was supporting people , sure , but i was n't in the icu . so i felt selfish and guilty . i mean , hands down , the physicians and nurses were in the thick of it and there i was , having anxiety . and it felt ridiculous .
[doctor] well , honestly , you feel how you feel and what you were doing was n't easy as well , so ... but let's see . i need to just put this dax back to work . all right , so no other issues whatsoever ?
[patient] no .
[doctor] have you lost weight ?
[patient] no , but i stopped taking the camila birth control . my hunger level was at a new high . i mean , i was eating constantly . i felt like , " what is going on ? "
[doctor] all right .
[patient] and now i am feeling better .
[doctor] okay , that's good . and your masked face , though , it does look thinner .
[patient] well , the past six months i have lost some weight .
[doctor] okay , good . um , anything else going on ?
[patient] no .
[doctor] all right . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative/negative . um , have you ever had an abnormal pap ?
[patient] not with you , but i did around 2009 , and then i had to be seen every six months for a while . and then i had a normal pap .
[doctor] all right , well , let's just repeat it then .
[patient] yeah , that's fine with me , to be safe .
[doctor] okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under , and the potential for getting covid or the vaccine ... i have actually seen some , um , an increase in abnormal paps in people who have been fine for a while . so that's why i figure let's just check .
[patient] okay . i fight the vaccine fight every day at home because my husband is n't ready to get it . same with my daughter . she shares the same worries as her dad in how it'll impact her when she gets older .
[doctor] have you had the vaccine ?
[patient] yes , i have . and so has my son . he , um , has had his first already .
[doctor] okay . well , you know , you can only do what you can do .
[patient] yeah , i agree .
[doctor] all right . well , let's complete your exam .
[patient] all right .
[doctor] so let's take a deep breath . and again . all right , you can breathe normally . all right , and take one more deep breath . okay , now i'm gon na touch your neck . go ahead and swallow . perfect . and just place your hand above your head . okay , i do feel some little bumps .
[patient] yeah , but they're not as big as they were .
[doctor] mm-hmm . okay , in this breast it does feel a little bit denser . does it hurt at all ?
[patient] it does , where your left hand just was .
[doctor] okay , right here ?
[patient] yeah , down here . but whenever i breastfed , it was always sore there too . i had a clog and something else . the lumps do feel smaller , but they are still there , unfortunately .
[doctor] yeah , they are . uh , well now i do n't know , because if it was the progesterone , they would've gone away .
[patient] yeah .
[doctor] all right , well just let your knees just op- relax and open . how's the itching or discomfort ? are you still using the cream ?
[patient] yes , and i actually need to get that refilled for the first time ever .
[doctor] okay .
[patient] uh , but yeah , i use it once a week and it does help .
[doctor] okay , great . all right , looks good .
[patient] good .
[doctor] you can go ahead and sit up .
[patient] thank you .
[doctor] all right , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles , and you've had two cycles so far . so i think let's just keep monitoring them for now .
[patient] okay . and what could that mean ?
[doctor] well , so just like people have an increased risk of breast cancer , there's also an increased risk for breast issues . you know what i mean ? so for example , cysts and lumps and fibroadenomas , those are all benign things . they're annoying and require some workup , but they're all benign .
[patient] and i'm- i'm just worried because i'm almost 40 and my mom was almost 45 when she was diagnosed with breast cancer . so i mean , i know there's nothing i can do about it , but it's just i feel like , uh , we had it under control and now it is n't .
[doctor] well , i would n't say that . i mean , i feel like we're at a point where we have a good cadence for you having surveillance on things , and i think you are more aware of your breasts than ever before , and things actually have n't changed .
[patient] yeah .
[doctor] so those are all good things .
[patient] okay .
[doctor] because , um , if it was cancer , we'd actually , we would see some change .
[patient] we would ? okay , thank you for explaining that .
[doctor] yeah . so i know it's annoying and distressing , but i think that's where we're at . it's annoying that you have the breast issue , and it's annoying that we have to follow them .
[patient] yeah , i agree there .
[doctor] um , but the only extra that i could po- , uh , potentially do , is we could get a breast specialist on the team and have you start to follow with them . and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam , in the office , to check out it- check it out on their own . uh , they also have a lot more experience and more willingness to sometimes perform procedures earlier , if they think it needs , um , if they think it needs to be done . and i think they tend to be much quicker than , you know , like radiology as to biopsy it .
[patient] okay . i'll do whatever you think i should .
[doctor] all right . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule .
[patient] okay , i think that sounds great .
[doctor] all right . i do too . all right , well any questions or anything else we can discuss today ?
[patient] no , i think i'm all set .
[doctor] all right , good . all right , well have a good rest of your day and just give us a call if you need anything else .
[patient] all right , thank you . you have a good day too .
[doctor] all right .

CHIEF COMPLAINT

Follow-up bilateral breast cysts.

HISTORY OF PRESENT ILLNESS

Donna Torres is a 40-year-old female who presents for follow-up surveillance of bilateral breast cysts.

The patient reports continual presence of “lumps” in bilateral breasts with some soreness. She is being seen today for surveillance of the cysts. The patient is taking progesterone, which was initially prescribed to support normalization of menstruation, which was effective. She is also still using vaginal cream one time per week which has improved symptoms of itching and discomfort.

Her last pap smear was in 2019, with negative/negative results. She did have an abnormal pap smear in 2009, which resulted in repeat pap smears per 6 months until her results normalized.

Mrs. Torres experienced increased anxiety in 11/2021 and 12/2021, stating “it was brutal” and felt she could not manage her symptoms and sought treatment. Dr. Brown started the patient on Buspar, which has successfully controlled her anxiety. The patient relates her anxiety to work related stress and possibly aging. Her work involves supporting Covid evaluation centers and clinics. She confirms receiving both Covid vaccinations. Initially, she was experiencing spikes in anxiety prior to menstruation, but her anxiety then became more random with an unclear cause. To note, the patient was started on Singulair, which the patient was told could also cause anxiety.

The patient discontinued Camila birth control, which did result in a significant increase in appetite. This has resolved and she reports she has lost weight in the past 6 months.

Gynecologic History
Last pap smear: 2019.
History of abnormal pap smear: 2009.

PAST HISTORY

Medical
Bilateral breast cysts.
Anxiety.

SOCIAL HISTORY

Employed in healthcare, supports Covid evaluation centers and clinics.

FAMILY HISTORY

Mother, deceased age 45, from complications of breast cancer.

CURRENT MEDICATIONS

Buspar.
Singulair.

PHYSICAL EXAM

Genitourinary
Breast: Breast density.

ASSESSMENT

• Follow-up bilateral breast cysts.
• Pap smear.

PLAN

Follow-up bilateral breast cysts
Physical exam indicated stable breast density bilaterally. The patient is being seen regularly for monitoring. The plan is to continue close monitoring and the patient will be referred to breast specialist for additional review. The patient agreed to this plan.

Pap smear
Exam was normal. No additional treatment needed at this time.

INSTRUCTIONS

Schedule appointment with breast specialist. Call clinic with any additional concerns.


[doctor] sophia brown . date of birth , 3/17/1946 . this is a new patient visit . she's here to establish care for a history of dcis . we'll go over the history with the patient .
[doctor] hello , ms. brown .
[patient] hi . yes , that's me .
[doctor] wonderful . i'm doctor stewart . it's lovely to meet you .
[patient] you as well .
[doctor] so , you've come to see me today because you had a right breast lumpectomy last year . is that right ?
[patient] yes . on january 20th , 2020 .
[doctor] okay . and how have you been since then ? any problems or concerns ?
[patient] no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since .
[doctor] perfect . i want to back up and go over your history so i can make sure everything in your chart is correct and i do n't miss anything . so , i'll tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing . sound good ?
[patient] sounds good .
[doctor] great . so , i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram , or was it done because you felt a lump ?
[patient] it was just a normal one you're supposed to get every so often .
[doctor] i see . and then it looks like you had an ultrasound of your right breast on november 3rd , 2019 , which revealed a mass at the two o'clock position , 11 centimeters from the nipple in the retroareolar region . the report states the mass was point four by two by three centimeters .
[patient] yes , that sounds right . hard to remember now , though .
[doctor] yep , definitely .
[doctor] based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5th , 2019 . pathology results during that biopsy came back as grade two , er positive , pr positive , dcis , or ductal carcinoma in situ .
[patient] yes . unfortunately .
[doctor] i know . scary stuff . but you had a lumpectomy on january 20th , 2020 , which removed the eight millimeter tumor and margins were negative . the pathology confirmed dcis . looks like they also removed 5 lymph nodes , which , thankfully , were negative for malignancy . that's great !
[patient] yeah , i was definitely very relieved .
[doctor] and your last mammogram was in january 2021 ? and that was normal .
[patient] yes .
[doctor] okay . so , i feel like i have a good grasp of what's been going on with you now . and you're here today to establish care with me so i can continue to follow you and make sure you're doing well , right ?
[patient] yes . fingers crossed .
[doctor] definitely . we'll keep a close eye on you and take good care of you .
[patient] okay , sounds good .
[doctor] i have a few more questions for you . when was your last colonoscopy ?
[patient] i had one in 2018 and , if i remember correctly , i had one polyp and that was removed and it was n't cancerous .
[doctor] okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular adenoma . okay . and when was your last menstrual period ?
[patient] gosh . it was probably around 30 years ago .
[doctor] okay . do you have children ?
[patient] i do . i have five .
[doctor] ah , big family then . that's nice .
[patient] yes . and they're all having kids of their own now , so it's getting even bigger .
[doctor] i bet . sounds like fun .
[patient] it is .
[doctor] did you have any other pregnancies that were miscarriages or terminations ?
[patient] really , i did not .
[doctor] okay . so for the record , that's g5 p5 . and now that you're post-menopausal , are you currently or have you ever been on hormone replacement therapy ?
[patient] my primary care doctor gave me the option years ago but i decided against it .
[doctor] okay . and on your review systems form , you indicated that you've not had any recent weight loss or gain , headaches , bone pain , urinary symptoms , or blood in the stools . but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those .
[patient] okay . so i've seen doctors for all of those . they've said , excuse me , the back and knee pain are age-related . and the cholesterol is a fairly new diagnosis , but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication .
[doctor] okay . and your primary care doctor is following you for that , right ?
[patient] that's correct .
[doctor] okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit . is that all right ?
[patient] yes , and that's all .
[doctor] okay . so for your medical history , it's high cholesterol and stage 0 er/pr positive invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ?
[patient] i did have my tubes tied after my last baby , but that's all .
[doctor] okay . and how about family history ?
[patient] my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it .
[doctor] all right . any family history of breast cancer ?
[patient] none .
[doctor] did any of your children have medical issues or siblings with medical problems ?
[patient] i do not have any siblings and , thankfully , my children are all healthy .
[doctor] wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ?
[patient] no drugs . i do drink socially , but never more than that . and i used to smoke , but really , everybody did back then and i probably quit about 30 years ago .
[doctor] excellent . i have that you're allergic to penicillin . any other allergies ?
[patient] nope , just penicillin .
[doctor] okay . i think that covers it . hop up here and let me take a look at you .
[doctor] okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes .
[doctor] in the result section , note that her ecog performance status today is zero .
[doctor] do you have ... did you have radiation after the lumpectomy ?
[patient] i did . we also talked about endocrine therapy , but i decided against that .
[doctor] okay . so your exam looks good , no masses , just some skin changes from that radiation . now , let's go over the plan for you .
[patient] okay , sounds good .
[doctor] as you know , you've had dcis which we'll list in my note as stage zero , er/pr positive , invasive ductal carcinoma of the right breast . your status post-lumpectomy with removal of five lymph nodes that were benign . you also had , um , radiation therapy but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy and your mammogram in january , 2021 was also negative for recurrence and malignancy .
[doctor] so , based on all of that , we can just continue to observe you .
[patient] okay . that sounds great . and when do i come back in to see you ?
[doctor] in a year , but you should have another mammogram in april of 2022 before you come back to see me .
[patient] okay , i can do that .
[doctor] wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ?
[patient] i do n't think so .
[doctor] okay , great . my nurse will be in shortly to discharge you . take care !
[patient] you as well .

CHIEF COMPLAINT

History of right ductal carcinoma in situ (DCIS).

HISTORY OF PRESENT ILLNESS

Sophia Brown is a 75 y.o. female who presents today for a new patient evaluation due to her history of right DCIS. She is doing well but wishes to establish care today for continued monitoring.

The patient underwent a screening mammogram in 10/2019 and was found to have a calcification in the right breast. She then had a right breast ultrasound on 11/03/2019 which revealed a mass at the 2 o’clock position, 11 cm from the nipple, in the retroareolar region. The report states the mass was 0.4 by 2.0 by 3.0 centimeters. She subsequently had an ultrasound-guided core needle biopsy on 12/05/2019 and pathology results revealed grade 2 ER-positive, PR-positive DCIS. The patient then had a lumpectomy with lymphadenectomy performed on 01/20/2020. The tumor was 8 mm with negative margins and the 5 lymph nodes removed were all benign. Pathology from the tumor confirmed DCIS. Her lumpectomy was followed by adjuvant radiation therapy. Endocrine therapy was also offered but the patient declined. She has since had a mammogram in 01/2021 which was normal. The patient also reports that she performs self-breast exams regularly at home.

Mrs. Brown is a G5P5 female and estimates that her last menstrual period was approximately 30 years ago. She is not currently and has never been on hormone replacement therapy.

The patient’s last colonoscopy was done in 2018. She had a sigmoid polypectomy at that time and pathology showed a tubular adenoma.

Her cholesterol was recently noted to be elevated and the patient reports that she is exercising and reducing fatty food intake accordingly. This is being followed by her primary care provider.

PAST HISTORY

Medical
Hypercholesterolemia.
Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast, status post lumpectomy and adjuvant radiation therapy.

Surgical
Right lumpectomy, lymphadenectomy x5, 01/20/2020.
Bilateral tubal ligation.

SOCIAL HISTORY

Alcohol: Socially. No history of heavier consumption.
Illicit drug use: Never.
Tobacco: Former smoker. Quit approximately 30 years ago.
Patient has 5 children and multiple grandchildren.

FAMILY HISTORY

Mother: Non-Hodgkin’s lymphoma.
Father: Prostate cancer, heart disease.
Her children are healthy. She has no siblings. Denies family history of breast cancer.

CURRENT MEDICATIONS

Co-Q 10.
Vitamin D.
Vitamin C.
Fish oil.
Elderberry fruit.

ALLERGIES

Penicillin.

REVIEW OF SYSTEMS

Negative for weight loss, weight gain, headaches, bone pain, urinary symptoms, blood in the stools.
Positive for back pain, joint pain, high cholesterol. Patient has sought care for these complaints. She reports that she was told the back pain and joint pain (knee) are age-related. She is being followed for the high cholesterol by her primary care provider.

PHYSICAL EXAM

The ECOG performance status today is grade 0.
Breast: There are no palpable masses; however, there is some skin thickening at the medial inferior aspect of the right breast which may be radiation skin changes.

ASSESSMENT

Stage 0 ER/PR-positive invasive ductal carcinoma of the right breast.
The patient is status post lumpectomy with removal of 5 lymph nodes which were benign. She also underwent adjuvant radiation therapy but declined endocrine therapy. Today’s clinical examination shows no evidence of recurrent disease or other malignancy. She also had a negative mammogram in 01/2021.

PLAN

1. We will continue to observe the patient.
2. She is due for a mammogram in 04/2022.
3. She should follow up with me in 1 year after the mammogram.


[doctor] good morning ms. reyes !
[patient] good morning .
[doctor] how are you doing ma'am ?
[patient] i'm doing well doctor , how are you ?
[doctor] i am fine thank you . so you've been having some problems with your right hip ?
[patient] yeah .
[doctor] okay , and where are you hurting ? can you show me ?
[patient] right in the groin area .
[doctor] okay , and this has been going on since february 2020 ?
[patient] yeah .
[doctor] okay . and is it worse with movement ?
[patient] well when it catches and i almost fall , yeah .
[doctor] okay . so it kinda grabs you ?
[patient] yeah .
[doctor] okay , and this all started when you were walking ?
[patient] well , walking around the infusion room .
[doctor] okay .
[patient] so it started if i took a step back or , you know , stuff like that . now it happens anywhere .
[doctor] okay , so now it hurts whenever you move ?
[patient] it hurts when i pivot .
[doctor] okay . so if you pivot then it hurts , got it . um ...
[patient] anything can sometimes do it . sometimes it wo n't though , and sometimes it'll do it several times in a row .
[doctor] several times in a row , okay .
[patient] and sometimes i fall .
[doctor] okay . and you rate the pain to range from two through seven out of 10 ?
[patient] yeah , that's correct .
[doctor] okay . and are you experiencing fever or chills ?
[patient] no .
[doctor] okay . and any tingling or numbness ?
[patient] no .
[doctor] and have you had any problems with your bowel or bladder ?
[patient] no .
[doctor] okay . and if you stay still , do you feel better ?
[patient] yes , but i do n't want to stay still .
[doctor] i understand , no problem . and for past medical history , do you have anything going on ?
[patient] i've had a lot of surgeries . i've had pcl , i had infertility , a gall bladder removed , but that's it .
[doctor] okay . and for family history , it looks like there's high blood pressure , diabetes , thyroid disease , heart disease , kidney disease and gastric ulcers . for your current medications , it does n't look like you're taking anything at this time . and you're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ?
[patient] yes , i've lost 110 pounds .
[doctor] that is awesome . and how did you do that ?
[patient] with weight watchers .
[doctor] that's great .
[patient] mm-hmm .
[doctor] and how many months have you been participating in weight watchers ?
[patient] i started in 2018 , and i've been at my current weight for a little over a year .
[doctor] that is awesome .
[patient] yeah , thank you .
[doctor] yeah , very good , and congratulations . and so , for social history , it looks like you work at an infusion center ?
[patient] yes , over at .
[doctor] okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month .
[patient] that's correct .
[doctor] all right . well let's go ahead and take a look at your hip .
[patient] okay .
[doctor] please use my general physical exam template . physical exam . ms. reyes is a pleasant 56-year-old woman who is five feet , six inches in height , weighing 169 pounds . blood pressure is 115 over 75 . pulse rate is 67 . ankles , no ankle edema is noted , no calf tenderness . okay , ms. reyes , can you go ahead and stand up for me please and take a couple of steps ? great .
[patient] okay .
[doctor] and can you walk on your tippy toes ? good , okay . and can you walk on your heels ? kind of a heel walk and toe walk are intact . um , go ahead and turn around please .
[patient] okay .
[doctor] examination of the cervical spine , any pain here now ?
[patient] no .
[doctor] okay , no tenderness . look at your right and your left and then over to the right , then go ahead and look up , then look down , and look straight ahead . range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ?
[patient] no .
[doctor] okay . skin is intact , no midline tenderness to palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ?
[patient] no .
[doctor] okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ?
[patient] no . i did or do have several bulging discs .
[doctor] okay . but you're not hurting right now ?
[patient] no , the weight loss has really decreased all the pain .
[doctor] okay . range of motion is decreased in exertion . lateral flection without pain . any pain when i push ?
[patient] no .
[doctor] okay . you can go ahead and , um , sit down please . no pain ?
[patient] no .
[doctor] okay . sacroiliac signs are negative . examination of the hips . trochanteric is non tender . go ahead and lift your knee up , does that bother you ?
[patient] um , just a little bit .
[doctor] okay , little bit . and then back one , probably bothers you ?
[patient] right there , like there , yeah .
[doctor] okay . how about this way ? not too bad ?
[patient] no .
[doctor] okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . okay , go ahead and keep it up , do n't let me push it down . does that hurt ?
[patient] right there .
[doctor] okay . resisted right hip flection causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ?
[patient] yeah .
[doctor] okay . motor control is normal in the lower extremities . go ahead and lift your knee up .
[patient] okay .
[doctor] okay , lift it up . any pain ?
[patient] no .
[doctor] okay . and this one ?
[patient] yeah .
[doctor] and squeeze your knees together , push it out and kick your leg out straight . now go ahead and bring it back and kick it out straight again . and go ahead and lean back , keep it loose . okay , all set . you can go ahead and sit up now .
[patient] okay , thank you .
[doctor] you're welcome . so what i think we're dealing with is right hip degenerative joint disease .
[patient] okay .
[doctor] and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort , as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain .
[patient] hmm , i do n't love that idea but i'll give it a try .
[doctor] okay , that would be great . and we can also try a cortisone injection into the right hip joint to see if that offers any relief .
[patient] i would like to definitely get the injection .
[doctor] okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed .
[patient] okay , that sounds good .
[doctor] okay . and here are the risks associated with getting the inje- injection . um , please just take a moment to review it and consent to the shot .
[patient] i'm good .
[doctor] great . we'll get that set up for ya . all right , well i hope things , um , feel better , and we will see you back here in three months .
[patient] see you . have a nice day .
[doctor] thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile and covid . she understood and decided to proceed with the injection . she will follow up with me in three months for another injection if needed . end of dictation .

CHIEF COMPLAINT

Right hip pain.

HISTORY OF PRESENT ILLNESS

Elizabeth Reyes is a 56-year-old female who presents for the evaluation of pain in her right hip and groin region. Her symptoms started on 02/2020 and has progressively worsened. She is employed as an RN and notes that her symptoms began while she was working and walking around the infusion room at Johnson. Initially the pain would only happen when she took a step back, but the pain has progressed and now occurs with any type of movement involving her right hip and groin. She describes that her hip will sometimes “catch” when she moves, causing her to fall on occasion. The pain improves when she is still and stops moving. She rates her pain as 2-7/10.

Starting in 2018, the patient intentionally lost 110 pounds through Weight Watchers. She has maintained the weight loss and her weight has been stabile for the past 1 year. She has a history of several bulging discs, but the pain has significantly reduced due to her weight loss. Today, she reports no back pain.

She denies fever, chills, new onset of bowel or bladder dysfunction, tingling or numbness.

Opioid Assessment

Opioid Use: No.

Pain Assessment

Pain is frequent.
Quality of Pain: Right hip catches.
Intensity of Pain Using VAS 0-10 Scale (0 = No pain, 10 = Worst imaginable pain)
• Current Pain Intensity: 2/10.
• Average Pain Intensity Over the Past Week: 4/10.
• Pain at Best: 2/10.
• Pain at Worst: 7/10.
Relieving Factors: Lying down, sitting.
Aggravating Factors: Walking, pivoting, turning, any movement engaging right hip.

PAST HISTORY

Medical
PCOS.

Surgical
Cholecystectomy.

SOCIAL HISTORY

Works at the infusion center at Johnson. Lives with a roommate. Denies tobacco use. Limits alcohol intake to less than 5 drinks per month.

FAMILY HISTORY

Hypertension.
Diabetes.
Thyroid disease.
Kidney disease.
Gastric ulcers.

CURRENT MEDICATIONS

NSAID PRN by mouth.

ALLERGIES

Percocet.
Vicodin.
Reglan.

VITALS

Blood pressure: 115/75
Pulse: 67.
Height: 5’6.
Weight: 169 lb.

PHYSICAL EXAM

Constitutional
Pleasant.

Integumentary
Skin is in tact.

Musculoskeletal
Extremities: No bilateral ankle edema or calf tenderness.
Examination of gait: Heel-walk and toe-walk are intact.
Cervical spine exam: No tenderness is elicited. Range of motion is full in all planes without pain. Spurling's test is negative.
Lumbar spine exam: Range of motion is decreased in extension and lateral flexion without pain. No tenderness is elicited in the midline.
Sacroiliac joint exam: Bilateral sacroiliac joints are nontender to palpation.
Bilateral hip exam: Range of motion is decreased in the right hip with pain in the groin on internal and external rotation. Resisted right hip flexion causes pain in the right groin region. Bilateral trochanteric regions are nontender to palpation.

Neurological
Motor bulk and tone are normal in both lower extremities. Motor strength testing reveals no focal motor weakness in the lower extremities. Deep tendon reflexes are 1+ throughout. No focal sensory deficit is noted.

RESULTS

MR arthrogram of the right hip completed on 06/03/2021 reveals evidence of high-grade chondromalacia involving the anterosuperior right acetabulum with subchondral marrow edema and cyst formation.

ASSESSMENT

• Right hip degenerative joint disease.

PLAN

I discussed the clinical and radiological findings with the patient. Treatment options discussed are low impact exercises, use of analgesics as needed, and use of a cane to offload the right hip. She would like to proceed with a cortisone injection into her right hip joint. We will administer the injection today. I reviewed the procedure in detail, including the risks of the injection related to the use of steroid in the COVID setting. She understands the risks and would like to proceed with the injection.

INSTRUCTIONS

Schedule a follow up appointment in 3 months to assess her pain. If needed, a second injection may be administered.


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

CHIEF COMPLAINT

Right knee pain.

MEDICAL HISTORY

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

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain and swelling.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
No murmurs, gallops.

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

ASSESSMENT AND PLAN

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

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

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


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

CHIEF COMPLAINT

Left shoulder pain.

HISTORY OF PRESENT ILLNESS

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

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

REVIEW OF SYSTEMS

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

VITALS

All vital signs are within the normal limits.

PHYSICAL EXAM

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

RESULTS

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

ASSESSMENT

Left shoulder pain, likely rotator cuff tendinopathy.

PLAN

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

INSTRUCTIONS

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


[doctor] well hello christina so how are you doing i was notified you were in the hospital for some heart failure what happened
[patient] well i'm doing better now but i just started having problems that my ankles were swelling and could n't get them to go down even when i went to bed and could n't breathe very good had to get propped up in bed so i could breathe at night and so i just really got to feeling bad i called my friend diane and she said i probably ought to call nine one one since i was having a hard time talking and so i called nine one one and they sent out an ambulance and they took me into the er on the it was quite an experience
[doctor] yeah
[patient] having an ambulance ride and and i've never done that before so not an experience i wan na do again either
[doctor] i'm sure you do n't yeah i see that your blood pressure was high also it was two hundred over ninety have you been
[patient] yeah i guess is that really high
[doctor] yeah that's
[patient] i feel really bad
[doctor] yeah that's pretty high are you taking your medications or you missing some doses
[patient] i do n't know i might miss one now but i try to take them all time
[doctor] yeah yeah you really need to take them very consistently now you also said you were watching your diet did you did you have some slips with that you said your ankles were swelling
[patient] no i yeah i do i like to i like to eat
[doctor] are you eating a lot of salty foods and pizza or
[patient] i like potato chips
[doctor] yeah
[patient] i like the salt and vinegar potato chips they're really good so
[doctor] well so do you do you go out to eat a lot or do you where you where where are you eating those potato chips or is that just the home snacking or
[patient] that's home snacking i buy the the the the brand name salt and vinitive because brand wo n't taste real good but the the brand names really tastes good
[doctor] oh
[patient] so i eat those probably everyday
[doctor] goodness well you know you we need to probably stop eating those now
[patient] yeah well i hate to hate to give those up but i guess i might have to
[doctor] well since you've been in the hospital and and they've helped you out with some with all that how are you feeling now
[patient] well i'm i'm doing better
[doctor] mm-hmm and they
[patient] i do n't do n't have quite as much shortness of breath i think maybe getting up and walking a little more is helping
[doctor] and they gave you a water pill and is that is that helping is that making you pee a lot
[patient] yeah yeah i have almost incontinence so
[doctor] goodness
[patient] yes that's not very pleasant at all
[doctor] and so they added another blood pressure medication also how are you doing with that are you feeling a little bit better
[patient] yeah i think so
[doctor] okay
[patient] if i can remember to take the pills
[doctor] yeah
[patient] that seems to be a sticky point
[doctor] well a a pill box or maybe setting an alarm on your phone might really help
[patient] okay i'll i'll give that a try anything that will help
[doctor] yeah okay well that's good to hear so now have you bought a blood pressure cuff to have at home now
[patient] yes i already had one but i very failed if i ever used it
[doctor] okay
[patient] but
[doctor] got it
[patient] i'll i'll try to use it everyday now
[doctor] okay and you might even just keep a log of what your blood pressures are and when it's up think about you know what you've eaten if you've done something different because that may help you to figure out what you need to cut back on or how you might need to change your your eating habits a little bit so
[patient] okay okay
[doctor] have you been short of breath or any problems sleeping since you've been home
[patient] no i've been sleeping like a log
[doctor] okay good alright have you had any chest pain
[patient] no no chest pain
[doctor] okay alright well let's do a quick physical exam here so your vital signs your blood pressure looks pretty good today at one twenty eight over seventy two your temperature is ninety eight . seven and your heart rate is seventy two your respirations are eighteen your oxygen saturation looks pretty good at at ninety six percent okay now on your neck exam there is no jugular venous distention on your heart exam i appreciate a two over six systolic ejection murmur which i've heard before and so it's stable and your lungs are clear bilaterally and your lower extremities show just trace edema now now we since we did the echocardiogram i reviewed those results and it does show a preserved ef of fifty five percent abnormal diastolic filling and mild-to-moderate mitral regurgitation so let me tell you a little bit about my assessment and plan so for your first problem for your congestive heart failure it sounds like this was caused by dietary indiscretion and some uncontrolled hypertension so i want you to continue on your bumex two milligrams once daily continue to watch your diet and avoid salty foods might try keeping that log we talked about with your blood pressures and what you've eaten if if your blood pressure seems a little high also weigh yourself daily and call me if you gain three pounds in two days okay
[patient] okay
[doctor] and i also want you to see a nutritionist to give you some education about what foods you can eat okay now for your second problem for i know this sounds like this is just for you and so for your second problem for your hypertension i want you to continue on the cozaar one hundred milligrams daily continue on the norvasc five milligrams once daily also and i'm going to order a renal artery ultrasound just to be sure we're not missing anything and then like maybe you know some renal artery stenosis or something and so so for your third problem for your kidney disease i wan na get some more labs to make sure you tolerate this the new medications and then i'll see you again in three months do you have any questions
[patient] no i do n't think so not today
[doctor] alright it's good to see you and i hope we'll just keep getting you feeling better
[patient] okay

CHIEF COMPLAINT

Emergency department follow up.

MEDICAL HISTORY

Patient reports history of hypertension.

MEDICATIONS

Patient reports taking Bumex 2 mg once daily, Cozaar 100 mg daily, and Norvasc 5 mg once daily.

REVIEW OF SYSTEMS

Constitutional: Denies sleep disturbance.
Cardiovascular: Denies chest pain.
Respiratory: Denies dyspnea.
Genitourinary: Reports urinary incontinence in the setting of diuretic medication.

VITALS

Blood Pressure: 128/72 mmHg
Temperature: 98.7 degrees F
Heart Rate: 72 bpm
Oxygen Saturation: 96%

PHYSICAL EXAM

Neck
- General Examination: No jugular venous distention.

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

Musculoskeletal
- Examination: Trace lower extremity edema.

RESULTS

Echocardiogram reveals a preserved ejection fraction of 55%, abnormal diastolic filling, and mild-to-moderate mitral regurgitation.

ASSESSMENT AND PLAN

1. Congestive heart failure.
- Medical Reasoning: This appears to have been caused by dietary indiscretion and uncontrolled hypertension.
- Patient Education and Counseling: I encouraged the patient to continue making dietary modifications, including limiting her sodium intake. She could try keeping a food diary, as previously discussed, to log her diet and associated blood pressure readings. I also advised her to monitor her weight daily and contact me if she gains 3 pounds in 2 days.
- Medical Treatment: Continue with Bumex 2 mg once daily. Referral placed for consult with a nutritionist for education and recommendations regarding her diet.

2. Hypertension.
- Medical Reasoning: This has been poorly controlled due to inconsistent compliance with medication and dietary indiscretion.
- Patient Education and Counseling: We discussed dietary modifications as noted above.
- Medical Treatment: She can continue on Cozaar 100 mg daily and Norvasc 5 mg once daily. Renal artery ultrasound ordered to rule out any issues such as renal artery stenosis.

3. Kidney disease.
- Medical Treatment: Labs will be ordered to assess her response to new medications.

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

INSTRUCTIONS

The patient will follow up in 3 months.


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

CHIEF COMPLAINT

Left wrist and hand pain.

HISTORY OF PRESENT ILLNESS

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

MEDICAL HISTORY

The patient denies a history of rheumatoid arthritis.

SOCIAL HISTORY

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

REVIEW OF SYSTEMS

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

PHYSICAL EXAM

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

ASSESSMENT

Bilateral carpal tunnel syndrome.

PLAN

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

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

INSTRUCTIONS

The patient will follow up with me in 2 weeks.


[doctor] hey dylan what's going on so i lift quite a bit of weights i try to stay in shape as much as i can i'm not like normal people i lift heavy weights and my elbow is extremely sore which elbow is it
[patient] actually it's both my elbows but my right elbow is hurting me the most
[doctor] okay and you said you lift a lot of weights
[patient] mm-hmm
[doctor] did you play any sports when you were younger
[patient] no anything you can think of primarily it was basketball baseball and football
[doctor] okay and did your elbows hurt at that time or is this a a new injury
[patient] it's new
[doctor] when did it start
[patient] probably year and a half ago
[doctor] okay on both elbows about a year and a half ago
[patient] yeah
[doctor] okay have you taken anything for the pain
[patient] ibuprofen eight hundred milligrams three times a day
[doctor] okay and does anything make it better or worse
[patient] the more i use my hands or my arms the more it hurts
[doctor] okay have you tried icing
[patient] yes
[doctor] does that give you any relief
[patient] no
[doctor] alright is it the inside or outside of your elbows
[patient] inside
[doctor] inside okay let's just do a quick physical exam here i'll take a look at your right elbow first
[patient] mm-hmm
[doctor] if i bend it this way up does it hurt it's your left does that hurt
[patient] yes
[doctor] how about this
[patient] yes
[doctor] okay so pain with both flexion and extension
[patient] mm-hmm
[doctor] looks like you have little bit of limited range of motion on extension not on flexion though you said it hurts right here on the inside of your elbow
[patient] yes
[doctor] okay so pain on the medial side with palpation
[patient] yes
[doctor] alright how about the outside
[patient] no
[doctor] no pain with palpation outside of the elbow you have do you have normal sensation in your fingers
[patient] i think so
[doctor] yeah
[patient] yeah
[doctor] okay great
[patient] good to go
[doctor] sensation is normal to the touch
[patient] yes
[doctor] pulses equal in all extremities how about the left elbow same thing if i bend it this way does that hurt
[patient] not as much
[doctor] how about this way
[patient] not as much
[doctor] alright so little bit of pain on flexion and extension little bit of limited range of motion on extension of the arm how about if you twist like you're opening a door
[patient] yes
[doctor] okay so some pain with torsion and twisting supination what about pronation
[patient] no
[doctor] no pain with pronation on the right side
[patient] mm-hmm
[doctor] same thing on the left
[patient] yes
[doctor] pain with supination no pain with pronation
[patient] correct
[doctor] alright so dylan it took some x-rays coming in looks like you do n't have any any fractures or any bony misalignment which i expect with this kind of injury i do think that what you have is medial epicondylitis which is
[patient] is that golfer's elbow
[doctor] yes same thing have you been golfing a lot
[patient] well not in the past year and a half i've had this for a long time
[doctor] okay also known as pictures elbow
[patient] well i have n't been pitching either
[doctor] hmmm well in any case what i'm gon na have to do is i'm gon na send you up for mri to take another look at this
[patient] mm-hmm
[doctor] that will be our next step so we'll get you scheduled for the mri probably get you in pretty quick here since we're a private practice
[patient] thank god
[doctor] yeah and once you get the mri i'll know a little bit more what i'd like to do is something called a whole blood transfusion have you heard of that before
[patient] no please tell me remind me
[doctor] yeah it should help with the healing of your elbow it's just a procedure we'll stick a needle in your elbow
[patient] you do a stick needle in my elbow
[doctor] mm-hmm and help with some of the healing of your elbow
[patient] so it's kinda like dry needling then
[doctor] no
[patient] not at all
[doctor] what is it
[patient] is it is that that thing where like you take the blood out of like say my my thigh
[doctor] mm-hmm
[patient] and then you literally inject it into my tendon
[doctor] yes
[patient] that it activates the healing
[doctor] yeah that's exactly what it is
[patient] interesting cool
[doctor] yeah
[patient] maybe i have heard about that
[doctor] we've we've had some really good responses from other patients on it so hopefully i mean that should be a good solution for you since you've been having issues with this
[patient] i'm excited
[doctor] yeah and we can hopefully get you scheduled for that in the next couple of weeks it's not not a major procedure and you should heal in the next two weeks so that wo n't be a problem especially considering that you're expecting a newborn soon we want to make sure you're all healed for that
[patient] wow i did n't even say that
[doctor] i read it in your chart
[patient] man you doctors are good
[doctor] yeah anything else going on today
[patient] just trying to figure out how you're doing
[doctor] very good thank you
[patient] you're welcome
[doctor] nice to see you
[patient] you have a good day

CHIEF COMPLAINT

Bilateral elbow pain, right worse than left.

HISTORY OF PRESENT ILLNESS

Dylan Bennett is a pleasant 53-year-old male who presents to the clinic today for the evaluation of bilateral elbow pain, right worse than left.

The patient has been experiencing bilateral elbow pain, right worse than left, for approximately 1.5 years. His pain is localized to the medial aspect of his elbows and is described as being extremely sore, worse with increased use of his upper extremities. Of note, he utilizes heavy weights for strength training and was very active in sports when he was younger, primarily playing basketball, baseball, and football, but he denies having any pain at that time. Applying ice to the area has not been helpful, but he does use ibuprofen 800 mg 3 times daily.

SOCIAL HISTORY

The patient reports that utilizes heavy weights for strength training. He was also very active in sports when he was younger, primarily playing basketball, baseball, and football.

He is expecting a newborn baby in the near future.

MEDICATIONS

The patient reports that he has been taking ibuprofen 800 mg 3 times daily.

REVIEW OF SYSTEMS

Musculoskeletal: Reports bilateral elbow pain, right worse than left.

PHYSICAL EXAM

CV: Pulses are equal in all extremities.
NEURO: Sensation is normal to light touch distally.
MSK:
Examination of the right elbow: Limited range of motion with extension with pain. Full range of motion with flexion with pain. Pain to palpation along the medial aspect. No pain to palpation on the lateral aspect of the elbow. Pain with supination. No pain with pronation.
Examination of the left elbow: minimal pain with flexion and extension Slight Limited ROM on extension of the arm. Pain with supination. No pain with pronation.

RESULTS

X-ray images of the bilateral elbows were obtained and review in office today. These reveal no evidence of fracture or bony misalignment.

ASSESSMENT

Bilateral medial epicondylitis.

PLAN

After reviewing the patient's examination and radiographic findings today, we had a lengthy discussion in regards to his current symptoms. I want to get an MRI of the bilateral elbows for further evaluation. We discussed the possibility of performing a whole blood transfusion to encourage healing, and the patient is already familiar with this procedure.