[doctor] so jerry is a 45 -year-old male who came in today with an ankle injury jerry what happened
[patient] hey doctor michael yeah so my son sean i think you met in the past he he started playing basketball and there we do multiple seasons and so we're kinda getting ready for the next season that starts in in april and we were at the courts plan and i went up for a shot and he's far more aggressive than with me than he is with you know his peers i guess he could say and so he he found me while i was going for a lap and then when i came down i kind of landed awkwardly and i kind of like rolled and twisted my my ankle so now it's it's hurting a bit like kind of on the outside you can you can even see it's it's bruised up and a bit swollen
[doctor] yeah
[patient] and yeah i've been having trouble walking and it just does n't feel solid really stable which is a problem i i recently got back into working out and i had been in a really good rhythm going to the gym
[doctor] okay
[patient] and i do n't want to disrupt that moments on because it took a lot for me to get back to a good place so
[doctor] absolutely okay totally understand that glad to hear that you're back out on the court playing with your son how is he doing by the way
[patient] he is doing great he is doing great i mean you know he is a big step kurry fan so he likes to keep up shots from from way out past the three point line and he is only ten and tiny so it's it's not a good idea for him to do that but he is doing really well and i'm just happy he's tried every sport and basketball's really what took so i'm just really happy that he has a sport and loves and couple of his buddies playing to lead with him so it's just makes me happy that he's found something he really enjoys
[doctor] good good to hear alright well let's take a look at that ankle it looks like it's pretty swollen so let me just do a quick exam on that right now alright so looks like the outside of your ankle if i push on that does that hurt pretty bad
[patient] yeah yes
[doctor] okay so exquisite tenderness tenderness laterally and then if i push here does that hurt too
[patient] yeah a little bit
[doctor] okay so some tenderness over the medial deltoid region so swelling on the lateral side of the ankle no epidermolysis skin is intact looks like you have brisk capillary refill no horrible malalignment so alright can you can you stand on it did you say that you're having trouble walking at all
[patient] yeah i mean i can stand on it and i ca n't walk on it it just it hurts and it feels like i'm going to possibly injure it more just because it does n't feel particularly solid
[doctor] sure so it does n't quite feel stable
[patient] yeah
[doctor] okay okay i gotcha so i know you had an x-ray as you came in today and so i'm just looking at this x-ray here i'll show you on the screen right here i can turn my monitor towards you this is an ap lateral oblique and this is your right ankle so what we're looking at is a displaced lateral malleolus at the weber c level there's no evidence of medial or posterior malleolar fractures but this is a fracture on the lateral side of your ankle now based on the position it's a bit unstable that's why you're feeling some of that that instability when you're walking so for your diagnosis what i'm gon na put down is a lateral malleolar fracture and what i would recommend for that since it is in the location that it is is you're probably unfortunately gon na need surgery we're gon na wan na get that healed what that includes is putting some plate and some screws in and you're gon na be out for a little bit so i know you've been trying to work out and and you wan na get back on the court but but you may have to have to sit out for a little bit we'll get you some crutches
[patient] how long it's a little bit because i'm also i i forgot to say i'm also i did volunteer to coach
[doctor] great
[patient] starting in april so
[doctor] alright well
[patient] how long
[doctor] yeah you you're probably gon na be out for about three months but continue the coaching go ahead and and let's get you back out there we'll get you some crutches and and hopefully you can kinda you know get back on the court start coaching and then within that three months we'll we'll get you back out doing some exercise again
[patient] okay
[doctor] alright in the meantime i'm gon na prescribe some medication for now let's try meloxicam and try to get some of the swelling down i want you to ice it and also keep that that ankle elevated do you have a job where you can elevate your ankle regularly
[patient] yeah i i work from home so that that should n't be a problem it's just everything else i do n't know who is gon na walk my dogs and and do all this stuff that's rest of my family refuses to walk my dog so we'll figure it out
[doctor] yeah i i'm a dog walker as well so alright sorry for the bad news but let's get you healed up so that we can get you back out doing everything you need to do
[patient] alright thank you doctor
[doctor] alright thanks

CHIEF COMPLAINT

Right ankle injury.

HISTORY OF PRESENT ILLNESS

Jerry Cook is a 45-year-old male who presents today with a right ankle injury.

The patient sustained an injury to the right ankle while playing basketball with his son. He reports he landed awkwardly and twisted his right ankle after jumping to make a layup. His pain is primarily located along the lateral aspect of the right ankle. He notes bruising and swelling. The patient is able to weight-bear while standing. He experiences pain and feelings of instability within the ankle while ambulating and is concerned for further injury.

SOCIAL HISTORY

The patient works from home and plans to coach his son’s basketball team in 04/2022. He enjoys working out and reports he recently resumed engaging in a consistent gym routine.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right ankle pain and instability.
Skin: Reports right ankle bruising and swelling.

PHYSICAL EXAM

CV: Brisk capillary refill.
SKIN: No epidermolysis. Intact.
MSK: Examination of the right ankle: Exquisite tenderness laterally. Mild tenderness over the medial deltoid region. Swelling on the lateral side of the ankle. No horrible malalignment.

RESULTS

X-rays, including AP, lateral, and oblique views of the right ankle, were obtained in the office and reviewed today. These demonstrate a displaced lateral malleolus at the Weber C level. There is no evidence of medial or posterior malleolar fractures.

ASSESSMENT

Right lateral malleolar fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding treatment options. Recommendation was made for an open reduction internal fixation of the right ankle. We discussed the risks and benefits of the procedure as well as the postoperative recovery period following surgery. I advised that it will be 3 months before he can resume his exercise routine. In the meantime, I will prescribe meloxicam to reduce swelling. I recommended he ice and elevate the ankle as well. He will be given crutches to assist with ambulation.

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


[patient] miss edwards is here for evaluation of facial pain this is a 54 -year-old male
[doctor] how're you doing doctor cruz nice to see you today
[patient] good to see you mister edwards i'm doctor
[doctor] tell me what's been going on yeah so i've got this stabbing shooting pain i've had for a while you know and it it especially right here in my right face right in that cheek bone area it's sometimes it gets super hot i've had it for i think a couple of months now and i went to my family doctor and they said i should come see you
[patient] okay great i would like to ask you a little bit more about that
[doctor] had in your face do you remember how long that you had it probably for about two or three months just just came on slowly i started noticing it but now it's i have episodes where just shooting stabbing kind of a pain in my right cheek bone right face area
[patient] mm-hmm do you have any sensory loss meaning like numbness or tingling in that part of your face
[doctor] not that i've noticed no okay do you have any symptoms like this anywhere else on your face including the other side of your face
[patient] no it's just on the right side mostly not on the left side just on the right side of my face
[doctor] have you noticed any weakness on that side of the face like when you smile or while you're doing other things any weakness there not really i mean i've i've i've tried to you know when i smile my smile seems equal on both sides my eyes i do n't have any weakness there my vision seems to be unchanged but just this stabbing severe pain it's just like excruciating pain that i get sometimes does it happen on its own or there are certain things that trigger it
[patient] sometimes if i'm if certain temperatures seem to trigger it sometimes or if it's super where it's cold i get a trigger sometimes
[doctor] sometimes certain kind of sensory outside of the wind sometimes that seems to trigger it but that's about it
[patient] okay and anything that you've done to to that helps for a little bit when you
[doctor] pain excess
[patient] you know i've tried ibuprofen and motrin that had really has n't helped it just comes on suddenly and then it's kinda stabbing excruciating pain i've tried rubbing some you know some tiger balm on it that did n't work
[doctor] but that's you know so i i went to my family doctor and he said you know i really need to see a neurosurgeon
[patient] got it how long do these episodes last these pain
[doctor] you know it can last for anywhere from a few minutes to sometimes about an hour but generally generally a few minutes
[patient] any history of something like multiple sclerosis or any brain tumors that you know
[doctor] no nothing like that alright any other kinda headache symptoms that have anything like you had migraines or anything related to the headaches i mean i get occasional headaches but not really i do n't have a history of migraines but i occasionally get headaches like everybody else i take some tylenol that usually goes away but this is different
[patient] how severe is the pain on a scale of one to ten
[doctor] when it comes on it's like a ten it's like somebody is stabbing you with an ice pick and but usually you know after a few minutes usually it goes away but sometimes it can last up to an hour great so mister i would like to do a physical exam if that's okay with you
[patient] sure
[doctor] i would like you to follow my finger here and i see that you're following my finger in in both directions can you show me your teeth
[patient] that looks nice and symmetric i'm gon na rub my fingers next to your ear can you hear that
[doctor] yep
[patient] you can hear it on the other side as well
[doctor] yep
[patient] okay
[doctor] i'm gon na take this cotton tape and run it along the side of your face can you feel that okay
[patient] yeah it's a little bit numb on my right side not so much on my left side
[doctor] okay alright i'm gon na use this little needle here and i'm gon na poke here and i wan na see if you feel like it's being sharp or dull on that part of your face does that feel different or normal
[patient] it feels a little bit dull on my left on my right side my left side it feels sharp
[doctor] alright good well i had a chance to look at your mri
[patient] okay
[doctor] and i looked at your mri and it appears to have small blood vessel that is abutting and perhaps even pinching the trigeminal nerve the trigeminal nerve is nerve that comes from the brainstem that goes out to the face and provides the sensory inflammation from the face and you may have a condition called trigeminal neuralgia
[patient] okay
[doctor] where the nerve compression causes this kind of shooting electrical pain in the face how do we treat it
[patient] well the first line would be to try some medications usually we start with medications that are called gabapentin
[doctor] or tegretol these are medications that really help reduce the excitability of the nerve
[patient] okay
[doctor] most people can get the pain control with that but there are some people where the medications are n't gon na be enough and in that situation we would consider surgery i would n't i would n't recommend that now we usually try the medications first
[patient] for considering a surgery to decompress the nerve the root cause of the problem is the compression of the blood vessel against the nerve
[doctor] okay so we should be tried which one would you recommend the tegretol or yeah i think we could start with the tegretol to start with i just want to make sure that you understand some of the potential side effects that you can have with this
[patient] sure
[doctor] it's always a little bit of trial and error to figure out what the right dosing that would work for you but some common side effects can include you know memory loss tingling imbalance some people can actually have like dermatologic
[patient] skin reaction to this medication and particularly people who have eustachian descent so that we may do some genetic testing just to make sure that it will be safe for you
[doctor] okay sounds good let's do it
[patient] okay so i will prescribe that for you and then we will see how that goes and if your pain continues we can talk about different surgical options to treat the pain
[doctor] yeah i think i would like to try the tegretol first and if that does n't work then i can come back and so once should i come back and just to kinda check back with you and see if you know if it's had enough time for a fact or not
[patient] i think one month would be a great time to follow up
[doctor] okay sounds good so if you want to send that prescription over to my pharmacy that would be fine and then why do n't i come back in about a month and we'll go from there
[patient] great i'll see you then
[doctor] alright

CHIEF COMPLAINT

Right-sided facial pain.

REVIEW OF SYSTEMS

Eyes: Denies vision changes or weakness in right eye.
HENT: Reports right sided facial pain. Denies left sided facial pain. Neurological: Reports headaches. Denies sensory loss, numbness, or tingling in the right cheek. Denies right sided facial weakness.

PHYSICAL EXAM

Neurological
- Orientation: Light touch testing of the right side of the face reveals numbness when compared to the contralateral side. Pinprick testing is sharp on the left side of the face; dull on the right side of the face.

Ears, Nose, Mouth, and Throat
Bilateral finger rub test is negative.
- Examination of Mouth: Teeth are symmetric.

RESULTS

MRI of the head is reviewed today. This demonstrates a small blood vessel that is abutting, and perhaps even pinching, the right trigeminal nerve.

ASSESSMENT AND PLAN

1. Trigeminal neuralgia.
- Medical Reasoning: The patient has been experiencing facial pain for 2 to 3 months. A recent MRI revealed a small blood vessel abutting, or perhaps even pinching, the right trigeminal nerve. The root cause of his facial pain is the compression of the blood vessel against this nerve.
- Patient Education and Counseling: The patient and I discussed treatment options including medicating with gabapentin or Tegretol. I explained the common side effects associated with these medications can include memory loss, tingling, and imbalance. We discussed the need for genetic testing due to the possible side effect of dermatologic reactions in people of East Asian descent. We also briefly discussed surgical treatment to decompress the nerve, but this is not recommended at this time.
- Medical Treatment: A prescription for Tegretol will be sent to the patient’s pharmacy.

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

INSTRUCTIONS

The patient will follow up with me in 1 month. If at that time his facial pain persists, we may further discuss surgical options.


[doctor] hi michelle what's been going on the medical assistant told me that you injured your knee
[patient] yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since
[doctor] okay and were you able to ski down the hill or did you have to be taken down by the ski patrol
[patient] i had to be taken down by the ski patrol i was unable to bear weight
[doctor] okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside
[patient] it hurts on the outside but it also feels like it wo n't hold my weight
[doctor] okay so it feels like it's gon na buckle
[patient] hmmm yes
[doctor] okay alright and are you able to bend it
[patient] i was immediately after the injury but not really now
[doctor] okay and how about straightening it are you able to straighten it at all
[patient] somewhat but it really hurts when i try to straighten all the way
[doctor] okay alright now do you have any numbing or tingling in your toes
[patient] no
[doctor] okay and can you feel your toes okay
[patient] i think so
[doctor] okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do
[patient] i chase my two four -year-old
[doctor] okay do you have twins
[patient] i do
[doctor] nice that's great
[patient] yeah
[doctor] so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or
[patient] yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids
[doctor] okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy
[patient] yes
[doctor] okay and no high blood pressure diabetes anything like that
[patient] mm-hmm
[doctor] no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again
[patient] my right knee
[doctor] your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press
[patient] yes
[doctor] okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain
[patient] ibuprofen
[doctor] is that helping
[patient] somewhat yes
[doctor] okay alright do you want something stronger
[patient] no i'm okay
[doctor] alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured
[patient] hmmm no i not i i would like to get back to the running but currently not that active
[doctor] okay alright alright do you have any questions about anything
[patient] i think you've explained it well
[doctor] okay alright so i'll see you again soon okay
[patient] okay thank you
[doctor] alright take care bye

CHIEF COMPLAINT

Right knee injury

HISTORY OF PRESENT ILLNESS

Michelle King is a pleasant 44-year-old male who presents to the clinic today for the evaluation of a right knee injury. Her injury was sustained while skiing in Vermont last weekend after she caught her ski when coming off of the lift and fell. She reports a pop in her knee at the time of injury and has been experiencing pain since that time. Due to her fall she was unable to weight bear and had to be taken down by the ski patrol. She locates her pain to the lateral aspect of her knee and also describes the feeling of instability as well as buckling. At this time she is experiencing difficulty with knee flexion; however, she states this was not a problem immediately after the injury. Full knee extension is also quite painful for her. The patient denies any numbness or tingling in her toes. She is currently utilizing crutches for ambulation which were provided to her by the ski patrol. In terms of pain control, she is taking ibuprofen which is providing some relief.

MEDICAL HISTORY

Patient reports she is otherwise healthy and denies a history of high blood pressure or diabetes.

SOCIAL HISTORY

Patient reports she is very active with skiing and taking care of her 4-year-old twins. She mentions that she would like to get back into running at some point. She states that her husband is home with her, but he also works a job where he has gone quite a bit.

MEDICATIONS

Patient reports she is taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain and limited range of motion.
Neurological: Denies numbness or tingling in toes.

PHYSICAL EXAM

GAIT: The patient is ambulating with crutches.
CV: Regular rate and rhythm. No murmur.
RESPIRATORY: Lungs are clear to auscultation.
MSK: Examination of the right knee: Edema and effusion noted. Pain with palpation of the lateral knee. Decreased flexion and extension. Positive Lachman's. Palpable dorsalis pedis and posterior tibial pulse. No ankle edema.

RESULTS

4 views of the right knee were taken today. These reveal no bony abnormalities.

ASSESSMENT

Right knee pain, possible ACL tear.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have recommended that we obtain an MRI of the right knee to evaluate for a possible ACL tear. In the meantime, I have advised her to continue taking ibuprofen 600 to 800 mg every 8 hours as needed for pain. She will also be placed into a brace for increased knee support.

INSTRUCTIONS

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


[doctor] hey brandon you know glad to see you in here today i see on your chart that you're experiencing some neck pain could you tell me a bit about what happened
[patient] yeah i was in a car crash
[doctor] wow okay when was that
[patient] well which car crash
[doctor] okay so multiple car crashes alright so let's see if we can how many let's start
[patient] my therapist said well my well actually my mother said i should go see the therapist and the therapist said i should see the lawyer but my neck's hurting
[doctor] okay so i'm glad that you know you're getting some advice and so let's let's talk about this neck pain how many car crashes have we had recently
[patient] well the ones that are my fault or all of them
[doctor] all of them
[patient] i was fine after the second crash although i was in therapy for a few months and then after the third crash i had surgery but i was fine until this crash
[doctor] okay the most recent crash when was that
[patient] that's when i was coming home from the pain clinic because my neck hurt and my back hurt but that was in february
[doctor] okay alright so we had a car crash in february
[patient] what year it was which february it was
[doctor] okay so let's let's try with this one see what happens hopefully you remember i need you to start writing down these car crashes that this is becoming a thing but you know it's okay so let's let's say maybe you had a
[patient] you're not judging me are you
[doctor] no there's no judgment here whatsoever i want to make sure that i'm giving you the best advise possible and in order to do that i need the most information that you can provide me makes sense
[patient] yes
[doctor] alright so we're gon na say hope maybe that you had a car crash and we can verify this in february of this year and you've been experiencing some neck pain since then right
[patient] yes
[doctor] okay alright on a scale of one to ten what ten is your arm is being cut off by a chainsaw severe how bad is your pain
[patient] twelve
[doctor] okay terrible pain now i know you mentioned you had previous car crashes and you've been to therapy has anyone prescribed you any medication it's you said you went to a pain clinic yes
[patient] well they had prescribed it recently i was i was on fentanyl
[doctor] oh
[patient] i have n't gotten a prescription for several weeks
[doctor] okay alright and so we will be able to check on that when you take your medication so before you take your medication rather like are you able to move like are you experiencing any stiffness
[patient] yes but it hurts
[doctor] okay it hurts what kind of pain is it sharp is it dull is it throbbing
[patient] it's the sharp incapacitating pain i ca n't work
[doctor] wow okay are you having any headaches
[patient] of course
[doctor] any dizziness
[patient] just sometimes
[doctor] any visual disturbances is it hard to like are you
[patient] not recently no
[doctor] okay alright any numbness
[patient] yes
[doctor] where
[patient] my left arm and my right leg
[doctor] okay any spasms
[patient] of course
[doctor] okay where
[patient] my body hurts i told you my neck hurts
[doctor] okay so i no i'm absolutely i wan na make sure that we are gon na give you the medication that works like the best for you so i'm sorry if these questions seem like frustrating i would just wan na make sure that i understand what the problem is so
[patient] i saw pamela and doctor collins's office she's much nicer than you know
[doctor] i mean okay so you know what like maybe maybe pamela would be better like we could maybe talk talk about a referral if that would make you more comfortable
[patient] my lawyer told me to come here
[doctor] then you're stuck with me okay i'm so sorry but here it's we're gon na try and make it as good as possible alright so last thing i do wan na do my physical exam alright and i need you to let me know as as much as you as much as you can verbalize right so when i push here in the middle of your neck on top of the bone does it hurt
[patient] yes yes
[doctor] okay alright sorry what about on the side does that hurt
[patient] yes
[doctor] okay so pain on palpation both on the bony process and on the muscle can you move your neck from side to side can you move your neck can you swive it side to side no no alright so i'm i'm seeing i'm seeing some range of movement moderate range of movement that's fine okay i so when can you bend your neck forward that that's your whole body just just the neck are you capable of bending up
[patient] really hurts it really hurts
[doctor] okay it really hurts to bend forward and backwards okay alright so i'm just gon na make a little note here i do n't i do n't see any bruising i'm not noticing any swelling there is i i do n't see any laceration what
[patient] just sometimes it bruises
[doctor] okay sometimes alright that's fine i i just i'm not seeing one here today so that's okay alright so with that being said i do wan na ask have you been experiencing any fatigue are you tired
[patient] well since the accident yes
[doctor] okay alright just making sure okay so this is what this is my assessment and plan this is what we are gon na do i want to be able to like we had you do an x-ray before you came in here and looking at it i'm not noticing any fracture that's a really good sign considering how many car accidents we've been in lately
[patient] it hurts it hurts
[doctor] absolutely no i we're gon na address the pain so for my first so looking at your imaging results though i'm not seeing a fracture that's a great sign so for your first diagnosis i'm gon na say that you have what is called a neck sprain that
[patient] thinking are are you saying i'm thinking
[doctor] no not by any means i am saying
[patient] pain i have a lot of pain
[doctor] yes and your pain can be explained by multiple things but thankfully it's not a broken neck is that okay
[patient] yes
[doctor] alright so what we are gon na do when we are gon na like try and treat this as conservatively as possible
[patient] said it might be broken
[doctor] what
[patient] pamela said it might be broken
[doctor] if pamela said it's broken then you know what this is what we're gon na do we're gon na order something called a ct that's gon na give us even nope you know what let's upgrade to an mri it's gon na give us the most thorough image of everything that's going on the heart and the soft tissues is that gon na is that so that way we can really get a good image of what's happening inside right
[patient] okay because what the lawyer said i needed was an mri
[doctor] not a problem we're we're gon na make your lawyer happy next step we are going to try working like from the outside in so i do need you to work on getting like you're you're saying you've seen some bruising and some swelling yourself so i want you to put ice on that whenever you're experiencing that in the moment when you wake up i want you to do your best to just like i'm gon na give you some exercises on the sheet and i want you to roll through these exercises every morning right to just get some like movement and like free frenosive movement back into your neck i also wan na put you on a couple medications now i know that you said you were on fentanyl before that's a bit extreme and i i want i i i wan na like monitor this a little more conservatively so what we're gon na start with is something called robaxin
[patient] hurts a lot if i do n't get more fentanyl
[doctor] you know we can refer you to pain medicine if it really is getting that complicated but for this current period we're gon na put you on some robaxin it's gon na be fifteen hundred milligrams and you're gon na take that six to eight hours every six to eight hours and that really should help kinda relax the muscles in the area take off some of that tension and really help with that pain if you're noticing that the robaxin still is n't helping maybe then we can start we can like start using like a heat pad or maybe some icyhot the biofreeze is a really good one to kinda help with that and then we will refer you to physical therapy i think with the mri we can start evaluating maybe some additional steps so rather than you having to like take that fentanyl because i do n't want you to be in danger right like people i do n't want you to get rubbed so what we could explore are local injections right and we can refer you to pain medication and see about like locally injecting the area and that should be able to help you out hopefully with this
[patient] i ca n't go to work like this
[doctor] okay so if it's if it's that bad let's wait for the mri result we're gon na give you off for work because you know you ca n't move and we'll see what the mri says about what whether or not we can get you like true local injections in the moment is that alright for now
[patient] yeah
[doctor] okay okay any other questions
[patient] not right now
[doctor] alright

CHIEF COMPLAINT

Neck pain.

HISTORY OF PRESENT ILLNESS

Brandon Green is a pleasant 46-year-old male who presents to the clinic today for the evaluation of neck pain. His pain began when he was involved in a motor vehicle accident in 02/2022 when he was on his way home from a pain clinic. The patient notes that he has been in 4 motor vehicle accidents; however, he notes that he was fine after the first two accidents, but the third motor vehicle accident is when his neck and back pain began. He states that he was in therapy following the second accident and had surgery after his third accident. The patient was seen at a pain clinic secondary to neck and back pain. He was prescribed fentanyl; however, he has not received a prescription for several weeks. Today, he reports that his pain is a 12 out of 10. He describes his pain as sharp and incapacitating with stiffness and pain. The patient also reports headaches, occasional dizziness. He denies any recent visual disturbances. He also reports numbness in his left arm and right leg. The patient also reports spasms throughout his body. He states that he has been experiencing fatigue since the accident. He notes that he is unable to work with this much pain.

REVIEW OF SYSTEMS

Constitutional: Reports fatigue.
Eyes: Denies any recent visual disturbances.
Musculoskeletal: Reports neck and back pain, and occasional swelling and bruising of the neck.
Neurological: Reports headaches, dizziness, spasms, and numbness.

PHYSICAL EXAM

SKIN: No lacerations.
MSK: Examination of the cervical spine: Pain on palpation on the bony process and muscle. Moderate ROM. No bruising or edema noted.

RESULTS

X-rays of the neck reveal no fractures.

ASSESSMENT

Neck sprain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any signs of a fracture. I recommended an MRI for further evaluation. I have also prescribed the patient Robaxin 1500 mg every 6 to 8 hours to treat his pain. I have also advised him to utilize ice, a heating pad, IcyHot, or Biofreeze on his neck as needed. I have also provided him with a home exercise program to work on his range of motion. I advised the patient that he will not be able to work until we have the MRI results.

INSTRUCTIONS

The patient will follow up with me after his MRI for results.


[doctor] hi , carolyn . how are you ?
[patient] good . how are you ?
[doctor] i'm good . you're ready to get started ?
[patient] yes , i am .
[doctor] so carolyn is a 49-year-old female here for follow-up of her chronic problems . so , how are you doing , carolyn ?
[patient] i'm doing okay . um , my osteoarthritis has been flaring up a little bit lately , um , so i wan na get- talk about that primarily . so , it's mostly in um , my elbows and it's really been bothering me . i've been sitting at the computer , at the desk more , um , in the office so i do n't know if it's being stagnant in that position all day has um , increased flare-ups for that , but i wanted to talk to you about that .
[doctor] okay , sure . and , are you right or left-handed ?
[patient] i'm right-handed .
[doctor] okay , and does one elbow bother you more than the other ?
[patient] my right elbow does bother me more than the other , but primarily , i'm typing all day versus writing , so it- it flares up in both .
[doctor] okay . all right , and um , any other joint pain ?
[patient] no , just- just really focused on my elbows .
[doctor] okay , and any numbing or tingling in your hands ?
[patient] uh , sometimes . when i'm typing for long periods of time , i feel a little bit of numbing , um , i try to shake out my arms a little bit . um , just to kind of relieve that um , sensation .
[doctor] okay . all right , and i know that you've had this also , had this history of gout . and the last episode you had was about three months ago . you had some inflammation of your toe . have you had any other issues with that ?
[patient] no , i have n't . um , the medication you gave me really controlled it , and i have n't seen a flare-up since .
[doctor] okay . all right , and how are you doing with your psoriasis ?
[patient] that's been under control too . that has n't been a- a major problem for me either .
[doctor] okay . i- i know that we had given you some clobetasol for your scalp . is that- so that's doing okay ?
[patient] yeah , that's doing a lot better .
[doctor] okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you .
[patient] okay .
[doctor] let's first look at your vital signs . hey , Sarah , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ?
[patient] yeah , that does hurt .
[doctor] okay , and when i turn your arm , do you have pain ?
[patient] yeah , that hurts a bit too .
[doctor] okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ?
[patient] yeah , it does and it's a bit stiff too .
[doctor] okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , Sarah . show me the autoimmune labs . hey , Sarah . show me the autoimmune profile . hey , Sarah . show me the esr . okay , so that's good . hey , Sarah . show me the uric acid . okay . all right , well , good . that's great . so , you know , it does n't look like you have any systemic arthritis , or sys- systemic inflammatory in process going on . so , my impression of you at this time is that from a gout standpoint , everything is nice and stable . i think that we should continue you on the colchicine 0.6 milligrams twice a day as needed for flare-ups of your gout . um , and then for your osteoarthritis , i'd like to go ahead and order a right elbow x-ray . hey , Sarah . order a right elbow x-ray , and then i'd like to prescribe some meloxicam 15 milligrams once a day for the pain and the swelling .
[patient] okay .
[doctor] hey , Sarah . order meloxicam 15 milligrams once a day . and then i'd like to um , just see those- how- the x-ray show- shows up and the results of that before we refer you for any type of physical therapy , okay ?
[patient] okay .
[doctor] and then from a psoriasis standpoint , i think everything is stable . we'll continue you on the steroid cream for your scalp , okay ?
[patient] that sounds good .
[doctor] all right , do you have any questions ?
[patient] no , that's it .
[doctor] all right , take care .
[patient] thank you .
[doctor] hey , Sarah . finalize the note .

CHIEF COMPLAINT

Follow-up of chronic problem.

HISTORY OF PRESENT ILLNESS

Ms. Carolyn Garcia is a 49-year-old female who presents to the clinic today for follow-up of her chronic problem.

The patient reports her osteoarthritis has been flaring up a little lately, and she would like to talk about that, primarily in her elbows. She states she has been sitting at the computer more in the office, so she is unsure if it is stagnant in that position all day. She notes her right elbow bothers her more than her left elbow, but she is primarily typing all day versus writing. She denies any other joint pain. She notes occasional numbness and tingling in her hands, which she tries to shake out her arms to relieve the numbness.

She also has a history of gout. Her last episode was about 3 months ago. She had some inflammation of her toe at that time. She denies any other issues with that. She states the medication she was given at that time helped with her gout and she has not seen a flare up since. She reports her psoriasis is under control and has not been a major problem for her either. She is still on colchicine 0.6 mg twice a day as needed for flare-ups of her gout.

REVIEW OF SYSTEMS

• Musculoskeletal: Endorses joint pain.
• Neurological: Endorses numbness and tingling.

PHYSICAL EXAMINATION

• Neck: Supple without lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm.
• Gastrointestinal: Abdomen is soft.
• Musculoskeletal: No edema to the lower extremity. Examination of  the right elbow, there is some edema and inflammation of the right olecranon. Some tenderness to palpation of the olecranon bursa. Pain with pronation and supination. Pain with flexion and extension of the right arm.

ASSESSMENT AND PLAN

A 49-year-old female here today for followup of chronic problem.

1. Gout
• Medical Treatment: Continue colchicine 0.6 mg twice a day as needed for flare ups.

2. Osteoarthritis
• Medical Treatment: We will order a right elbow x-ray. We will prescribe meloxicam 15 mg once a day for pain and swelling.

3. Psoriasis
• Medical Treatment: Continue steroid cream.

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


[doctor] good afternoon , beverly . good to see you .
[patient] nice to see you too .
[doctor] so , i know my nurse told you a little bit about dax . um , now , if you do n't mind , i'd like to tell dax a little bit about you .
[patient] go for it .
[doctor] great . um , beverly's a 24 year old female patient , and i know you have a history of type 2 diabetes and high blood pressure . correct ?
[patient] yep .
[doctor] okay . so , you're here today for your yearly exam . have n't seen you in a year . how're you doing ?
[patient] i've been doing well . i began working in a bakery this summer which has been super fun. i have really been enjoying working there, but i find myself, since i am so close to so many delicious treats, snacking a lot during shifts and eating a lot more desserts than i normally would.
[doctor] okay , so , that brings me to your diabetes . so , how have your blood sugars been ?
[patient] uh , not so good .
[doctor] okay .
[patient] so , they've been up and down because of my diet , i think , because i've been taking my medication as prescribed . um , so , i have n't missed anything there , but my diet has been pretty bad lately .
[doctor] pretty bad lately ?
[patient] yeah .
[doctor] okay . and , that's really the only thing that's different is your diet , pretty much ?
[patient] yeah .
[doctor] and , that's because of the new job and all that ?
[patient] yeah. it has been really challenging to resist the temptation.
[doctor] it's hard to ignore those desserts , are n't they ?
[patient] yeah .
[doctor] no willpower like me ?
[patient] no , no willpower .
[doctor] okay . all right . and , and then , um , i know you've had high blood pressure , hypertension . how is , how have your blood sugars been ? have you been checking them ?
[patient] so , my blood pressure's been good . um , despite my , um , my diabetes levels being up and down .
[doctor] okay .
[patient] so , that's been good .
[doctor] okay , so , your blood pressures have been normal . you've been sleeping well ?
[patient] yep , getting a full eight hours .
[doctor] no concerns about hurting yourself or anything like that ?
[patient] no .

[doctor] okay , good . okay , and i know my , um , nurse did a review of systems . other than what we've talked about so far , is there anything else that you needed to add ?
[patient] no .
[doctor] good . so , pretty much status quo except for those things that we've been working on , right ?
[patient] yep .
[doctor] okay , good . all right . well , let me do a quick physical exam , okay ?
[patient] okay .
[doctor] okay , squeeze my finger here . good . can you feel me touch out here ?
[patient] yep .
[doctor] okay . and , can you feel me touch you down here ?
[patient] yep .
[doctor] okay . no swelling . push your leg out . good . pull it back . mm-hmm . go . good . okay . so , on my exam , um , essentially , your exam is normal . your , um , heart is regular . you do have that grade 2 , um , systolic ejection fraction back ejection murmur that you , um , that we've heard in the past . okay ? so , um , we definitely know that's there . that's unchanged , okay ? um , your lungs are clear . um , your grips are equal . neurovascular's intact . you do n't have any carotid bruits in your neck , no thyromegaly . no edema . um , pulses are good , so essentially , your exam is , is essentially normal . let's take a look at some of your lab work , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the hemoglobin a1c . okay , so , blood sugars have been elevated . your hemoglobin a1c is elevated as well , so that tells me your blood sugars have been a little bit out of control . you're still taking the metformin , correct ?
[patient] yes , i am .
[doctor] okay , and you take that twice a day ?
[patient] yep .
[doctor] okay . um , uh , hey , Sarah ? show me the vital signs . okay , good news here is your blood pressure's good . everything , um , there is fine . so , um , so , my assessment is , is , um , your first problem is diabetes . it's a little out of control . we'd like that hemoglobin a1c to be under seven , um , at least . you know , preferably , under six .
[patient] mm-hmm .
[doctor] so , um , uh , i'm not gon na change your medication . i think this is diet related , so i want you to try to cut down on the snacking and additional sweets , okay ?
[patient] yeah .
[doctor] and , i want you to check your blood sugars in the morning . i want you to call them in in about two weeks so we know what your first , um , fasting blood sugar was in the morning , and then , we'll come back and see you in about two months and see if everything has straightened out . if it has n't , then we'll talk about adding another medication , okay ?
[patient] okay .
[doctor] your second problem is your hypertension . that seems to be relatively stable . i want you to stay on your current medication . you're on li- lisinopril 10 mg once a day . just stay right on that medication . no changes at this point . seems to be doing well , okay ?
[patient] okay .

[doctor] good . anything else i can do for you today ?
[patient] no . that's it .
[doctor] good . come with me , we'll get you checked out .
[patient] thank you .
[doctor] hey , Sarah ? finalize the note .

CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

Beverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.

The patient states she has been doing well. She has recently began working at a bakery this summer.

The patient states her diabetes is uncontrolled. Her blood sugars have fluctuated recently, which she attributes to her change in diet due to work. She is trying to improve her diet by removing additional sweets. She has been taking her medication as prescribed and has not missed any doses.

The patient states her blood pressure has been good despite her blood sugar levels being up and down. She has continued taking metformin twice a day.

She has been sleeping well and is able to sleep a full 8 hours. She denies thoughts of self-harm or suicidal ideations.

PHYSICAL EXAMINATION

• Neurological/Psychological: Grip strength equal bilaterally. Neurologically intact.
• Neck: Supple without thyromegaly or lymphadenopathy. No carotid bruits appreciable.
Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate. Grade 2/6 systolic ejection fraction murmur. No gallops or rubs. No extra heart sounds. Good pulses.

RESULTS

Hemoglobin A1c is elevated.

ASSESSMENT AND PLAN

Beverly Ortiz is a 24-year-old female patient with a history of type 2 diabetes and high blood pressure. She is here today for her yearly exam.

Diabetes mellitus type 2.
• Medical Reasoning: Her blood glucose levels have been uncontrolled. She is still taking metformin twice a day, but does admit to dietary indiscretion with an increase in her sweets intake.. Her most recent hemoglobin A1c was elevated.
• Medical Treatment: Continue metformin twice a day.
• Patient Education and Counseling: I encouraged her to check her fasting blood glucose levels each morning and call them in about 2 weeks. She will follow up in about 2 months, at which time we will discuss further treatment recommendations.

Hypertension.
• Medical Reasoning: Appears to be relatively stable.
• Medical Treatment: Continue lisinopril 10 mg once daily.

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


[doctor] hi , anna , how are you ?
[patient] i'm doing okay . how are you ?
[doctor] i'm doing well . uh , so i know the nurse told you a little bit about dax . i'd like to tell dax a little bit about you .
[patient] okay .
[doctor] all right . so , uh , anna is a 26-year-old female with a past medical history , significant for epilepsy , depression , and , uh , peptic ulcer disease , who presents with , uh , some joint pain . so , anna , what's going on with your , uh , what's going on with your joints ?
[patient] so , um , it's my left elbow that's really been bothering me . uh , i sit at my desk a lot for work , and type , and i stay in this motion specifically all day . and then after , um , work , it's really hard for me to , uh , open and , and close my , my elbow here , my left elbow , and it's been just really stiff and , and hurts .
[doctor] okay . have you noticed any swelling there on the-
[patient] yeah , i have .
[doctor] okay , and is it right here on the , on the tip ?
[patient] yep , it is .
[doctor] okay , and are you right or left-handed ?
[patient] i am right-handed .
[doctor] okay , so it's your non-dominant hand ?
[patient] yeah , which is good .
[doctor] yeah .
[patient] so , i can still write , which is great , but typing is , is difficult .
[doctor] okay , and any numbing or tingling in your hands at all ?
[patient] no , i have n't felt numbing or tingling .
[doctor] and any weakness in your arm ?
[patient] a little bit of weakness , uh , but nothing too significant .
[doctor] okay , and ... and how about ..
[doctor] and how about , um , any fever or chills ?
[patient] no fever or chills .
[doctor] okay . all right , well , let's talk a little bit about your epilepsy , okay ?
[patient] okay .
[doctor] um , have you had any recent seizures ?
[patient] uh , no , i have n't . i think my last seizure was a year ago .
[doctor] okay , good .
[patient] yeah .
[doctor] and you're still taking the keppra ?
[patient] yes , i am .
[doctor] okay , great . and then , tell me a little about your depression . how're you doing with that ? i know that you went into therapy last year , and you tried to avoid medication since you're already on the keppra . how's that doing ?
[patient] uh , therapy , therapy's been good . it , it has definitely helped . uh , i still feel a little down , uh , and , and stressed .
[doctor] okay . all right , but no , no feelings of wanting to hurt yourself or somebody else ?
[patient] no , nothing like that .
[doctor] okay . all right . and then , how are you doing with your , with your ulcer ? i know that you , you know , you had so much stress a year ago and , you know , you were having some issues there . we did the endoscopy-
[patient] mm-hmm .
[doctor] . and they showed that . so , how are you doing with that ?
[patient] i'm doing , i'm doing better . i have n't had any , um , issues with that , um , since we did the procedure , and everything's been good .
[doctor] okay , well great . let's go ahead and ... i'm gon na go ahead with , um ... and , you know , i know that the nurse did a review of systems sheet on you when you came in , and i know that you were endorsing that left elbow pain .
[patient] mm-hmm .
[doctor] any other symptoms , you know , chest pain , shortness of breath , abdominal pain , nausea or vomiting ?
[patient] no , nothing like that . i have a little bit of nasal , nasal congestion from allergies , uh , but that's it .
[doctor] okay , so you're endorsing some nasal congestion ?
[patient] yeah .
[doctor] okay . all right , well , let's go ahead to a physical exam , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the vital signs . good , here in the office , everything looks great with your vital signs . i think that's great , so i'm just gon na take a listen to your heart and your lungs , and take a look at your elbow and , and we'll go from there , okay ?
[patient] okay .
[doctor] all right , so , so on physical examination of your left elbow , you do have some erythema and edema of your left elbow . does it hurt when i touch ?
[patient] yeah , it does .
[doctor] okay , he ... she has some pain to palpation of the olecranon . of the left olecra- olecranon , and it is warm to palpation . um , can you straighten your elbow for me ?
[patient] yeah , it , it hurts , and it's , uh , it's a bit stiff .
[doctor] okay , so she has pain with flexion and extension of the left elbow . there's a palpable right ... or s- ... palpable left radial pulse . okay , um , so let's go over ... i just wan na take a look at some of your results , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the left elbow x-ray . hey , Sarah , show me the elbow x-ray . hey , Sarah , show me the left arm x-ray . okay , so , in reviewing the results of your left arm x-ray , there's no evidence of any elbow fracture , which is not surprising , okay ?
[doctor] hey , Sarah , show me the endoscopy results . hey , Sarah , show me the endoscopy . okay , well , your recent endoscopy showed that you ... hey , Sarah , show me the endoscope . all right , so here it looks like , you know ... your endoscopy results look like you had an episode of gastritis . that's for your , your peptic ulcer disease , and so everything , you know ... you took your , your protonix , and i think everything resolved at that point , okay .
[patient] okay .
[doctor] so , let's talk a little bit about my assessment and my plan for you . so for your first problem , this left elbow pain , you know , i think you have olecranon bursitis , and we're just gon na , you know , have you , you know , get a little pillow for your elbow there . it's just caused by repetitive trauma .
[patient] mm-hmm .
[doctor] so , maybe you're slamming your elbow down a little bit on the desk , so just get a little rest there-
[patient] yeah .
[doctor] . and we'll give you some melo- meloxicam , 15 mg , once a day . you can ice the area , okay ? um , for your next problem , the epilepsy , sounds like you're doing really well . i would go ahead and continue with the keppra , 500 mg , twice a day . do you need a refill of that ?
[patient] yes , i do .
[doctor] hey , Sarah , order a refill of keppra , 500 mg , twice daily . for your third problem , the depression , it sounds like you're doing well with the therapy and , if you want , we can talk about medical treatment options .
[patient] yeah , i think that would be great .
[doctor] okay , well , let's go ahead and we'll start you on some lexapro , 10 mg , once a day , and we'll see how you do on that , okay ?
[patient] okay .
[doctor] all right , and then , for your last problem , the peptic ulcer disease , um , i want you to continue on the protonix , 40 mg , once a day before meals , okay ?
[patient] okay .
[doctor] do you have any questions ?
[patient] no , i do n't .
[doctor] okay . all right . well , the nurse will come in soon and see you , okay , and i'll , i'll see you in a couple of weeks .
[patient] okay .
[doctor] all right , take care . bye .
[patient] bye .
[doctor] hey , Sarah , finalize the note .

CHIEF COMPLAINT

Joint pain.

HISTORY OF PRESENT ILLNESS

The patient is a 26-year-old female with a past medical history significant for epilepsy, depression, and peptic ulcer disease who presents with some joint pain.

The patient reports that her left elbow has really been bothering her. She states that she sits at her desk all day for work with her elbows bent. She reports that after work it is really hard for her to flex and extend her left elbow. She reports that it has been really stiff and painful. She also notes that she has noticed swelling on the olecranon of her elbow. She reports that she is right-handed, therefore, she can still write, which is great, but typing is difficult. She denies any numbness or tingling in her hands. She reports that she has some weakness in her arm but nothing too significant. She denies any fever or chills.

Regarding her epilepsy, she reports that she has not had any recent seizures. She reports that her last seizure was a year ago. She reports that she is still taking Keppra.

Regarding her depression, she reports that she started therapy last year and she is trying to avoid medications for this problem. She reports that therapy has been helpful, but she still feels down and stressed. She denies suicidal and homicidal ideations.

Regarding her peptic ulcer, she reports that she was dealing with a lot of stress last year. She then underwent an endoscopy which showed that she had an episode of gastritis. She was subsequently diagnosed with peptic ulcer disease and started Protonix. She reports that she has not had any issues with her ulcer since the procedure and everything has been good.

The patient denies chest pain, shortness of breath, abdominal pain, nausea, or vomiting. She reports that she does have a little bit of medial nasal congestion from allergies.

REVIEW OF SYSTEMS

• Ears, Nose, Mouth and Throat: Endorses medial nasal congestion from allergies.
• Cardiovascular: Denies chest pain or dyspnea on exertion.
• Respiratory: Denies shortness of breath.
• Musculoskeletal: Endorses left elbow joint pain, swelling, and weakness.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Musculoskeletal: Examination of the left elbow reveals erythema and edema. Pain to palpation of the left olecranon. Warm to palpation. Pain with flexion and extension. Palpable left radial pulse.

RESULTS

Left arm x-ray does not reveal any evidence of elbow fracture.

EGD revealed an episode of gastritis.

ASSESSMENT

Anna Morris is a 26-year-old female with a past medical history significant for epilepsy, depression, and peptic ulcer disease who presents with some joint pain.

PLAN

Left elbow pain.
• Medical Reasoning: I believe she has left olecranon bursitis caused by repetitive trauma.
• Medical Treatment: Initiate meloxicam 15 mg once daily.
• Patient Education and Counseling: I encouraged the patient to use a pillow to rest her arm on. She may also ice the area.

Epilepsy.
• Medical Reasoning: She has been doing well on Keppra and denies any recent seizures.
• Medical Treatment: Continue Keppra 500 mg twice a day. This was refilled today.

Depression.
• Medical Reasoning: She reports doing well with therapy.
• Medical Treatment: Initiate Lexapro 10 mg once daily.

Peptic ulcer disease.
• Medical Reasoning: Her recent endoscopy revealed gastritis
• Medical Treatment: Continue Protonix 40 mg once daily before meals.

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


hi , susan , how are you ?
[patient] good . how are you ?
[doctor] good . are you ready to get started ?
[patient] yes , i am .
[doctor] so , susan is a 26-year-old female here for a high blood pressure check . susan , what's going on with your blood pressure ?
[patient] so , i've always struggled with , um , high blood pressure , but it's seeming to get really out of control lately . so , i wanted to come in and see if there's any type of new medication i can be on to help it get steady or if there is diet restrictions i should take , um , things like that .
[doctor] okay . so , i know that we've had you on the norvasc and we had to increase your dose , so you're on 10 milligrams a day now . and what are your blood pressures running at home ? you c- ... like , have they been like over 150 ?
[patient] yeah , they have been .
[doctor] okay . all right . and , have you had any headaches ?
[patient] i have had some headaches . i do n't know if that's just because of more stress at work or , um , because of the high blood pressure .
[doctor] okay . all right . so , you've had some headaches . have you had any chest pain , shortness of breath , anything like that ?
[patient] no , nothing like that .
[doctor] okay . um , and , you know , i know that you've had a kidney transplant a few years ago .
[patient] yes .
[doctor] everything is okay with that ?
[patient] everything's been good and solid there .
[doctor] and you're taking all of your auto , um , i- um , your immunosuppression medications ?
[patient] yes , i am .
[doctor] all right .
so , let's go ahead and we'll do a quick physical exam . so , looking at you , you do n't appear any distress . your neck is nice and supple . your heart is irregular rate and rhythm . i do hear a slight , uh , two out of six systolic ejection murmur . your lungs are clear . i do see the scar on the left , uh , left plank for your kidney transplant which is healed . and you have no lower extremity edema . so , let's go ahead and look at some of your results , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the creatinine . so , your kidney function looks really good . so , that's really promising after your transplant . hey , Sarah , show me the ekg . and your ekg looks great , uh , perfectly normal , so that's good . um , so , my impression of you at this time ... , let me see your blood pressure .
[patient] okay .
[doctor] hey , Sarah , show me the blood pressure . yeah , and you're right , it-
[patient] hm .
[doctor] . it is high . so , there is something that we can do for that . so , let's go ahead and we'll put you on ... so , my impression of you is that your , your blood pressure is high and the norvasc is n't controlling it . and , you know , we can definitely get it under better control . so , what i would like to do is prescribe you coreg 25 milligrams , twice a day . and that will help bring your blood pressure down , okay ?
[patient] okay .
[doctor] hey , Sarah , order carvedilol 25 milligrams , twice a day . uh , i'd also like to go ahead and , uh , get a lipid panel and some routine labs on you just to make sure that everything is okay .
[patient] yeah .
[doctor] hey , Sarah , order a lipid panel . hey , Sarah , order a complete metabolic panel . all right . and then , um , from a transplant standpoint , everything looks fine . your kidney function looks great , so we're just gon na continue you on all of those medications .
so , the nurse will come in soon and she'll help you schedule all of the al- schedule a follow-up appointment with me , and we'll see what your blood pressure looks like in a couple weeks after taking that medication . okay ?
[patient] okay .
[doctor] all right . thanks , susan .
[patient] thank you .
[doctor] hey , Sarah , finalize the note .

CHIEF COMPLAINT

High blood pressure check.

HISTORY OF PRESENT ILLNESS

Ms. Susan Watson is a 26-year-old female who presents to the clinic today for a high blood pressure check.

The patient reports she has always struggled with high blood pressure, but it is seems out of control recently. She notes that she has interest in new medication or diet changes to help. She is currently on Norvasc 10 mg daily. Her blood pressure at home has been over 150. She notes she has had some headaches, but she is unsure if it is due to stress at work or her high blood pressure. She denies chest pain or shortness of breath.

The patient underwent a kidney transplant a few years ago, and everything is going well. She is taking all of her immunosuppression medication.

REVIEW OF SYSTEMS

• Cardiovascular: Denies chest pain or dyspnea on exertion.
• Respiratory: Denies shortness of breath
• Neurological: Endorses headaches.

PHYSICAL EXAMINATION

• Constitutional: in no apparent distress.
• Neck: Supple without thyromegaly or lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: 2/6 systolic ejection murmur.
• Musculoskeletal: No edema.
• Integumentary: Scar on left flank from kidney transplant, healed.

RESULTS

Creatinine: normal.

Electrocardiogram: normal.

ASSESSMENT AND PLAN

Ms. Susan Watson is a 26-year-old female who is here today for a high blood pressure check.

Hypertension.
• Medical Reasoning: Her blood pressure is elevated today and based on her recent home monitoring.
• Additional Testing: I would like to get a lipid panel and metabolic panel.
• Medical Treatment: carvedilol 25 mg twice a day to help bring her blood pressure down.

Status post kidney transplant.
• Medical Reasoning: Doing well.
Kidney function stable.
• Medical Treatment: Continue current medications.

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


[doctor] hello mrs. lee , i see you're here for back pain .
[patient] yes .
[doctor] hey Sarah , i'm seeing mrs. lee today for , uh , back pain . she's a 40-year-old female . so can you tell me what happened to you ?
[patient] yes . i was at a birthday party and it was surprise party . so we were all like crunched behind and hiding . and when the person came in we all jumped out , and then i fell down the little stair and i rammed my back into the railing of the s- , uh , staircase .
[doctor] so it was a surprise for you too ?
[patient] yes it was .
[doctor] very good . okay . so , um , did it hurt because you hit it , or did you twist ? what happened when you ?
[patient] i think it was my motion-
[doctor] okay .
[patient] . of jumping up , or something .
[doctor] okay .
[patient] and maybe a twisting .
[doctor] okay . any pain shooting down your legs at all ?
[patient] no .
[doctor] is it on one side or the other of your back ?
[patient] um , it's more on the right .
[doctor] on the right . is there anything that makes it better or worse ?
[patient] uh , if i'm lying flat it hurts a little more , and any twisting motion for sure .
[doctor] okay . all right . and do you have any history or any back problems before ?
[patient] i did . i had a fusion done .
[doctor] okay , yeah that lumbar fusion . um , let's take an x-ray . hey . or let's look at an x-ray . hey Sarah , show me the latest x-ray . okay , we can see where you had your fusion , t4 here on the x-ray . but i do n't see anything that looks , um , significantly abnormal . it does n't appear to have any compression fractures or anything like that . so , it's essentially , except for the fusion , a normal exam . let me do your exam for you here . can i have you stand up please ? does it hurt when i twist you that way ?
[patient] yes .
[doctor] okay . you can sit back down . if i lift your leg here , does that bother you ?
[patient] no .
[doctor] how 'bout when i lift this leg ?
[patient] no .
[doctor] any pain shooting down your legs when i do that ?
[patient] no .
[doctor] okay . and can you feel me touching down here .
[patient] yes .
[doctor] okay , great . so , you had a injury to your back when you were twisting at the birthday party . you do n't really have any pain or numbness down your legs . you have some stiffness with rotation , um , but you do n't have any evidence of a , um , what we would call a pinched nerved or radiculopathy . so , i think you basically have a strain of your lower back . um , have you been taking any medications ?
[patient] just some ibuprofen .
[doctor] okay . and do you have any other , um , medical problems ?
[patient] um i take medication for anxiety .
[doctor] okay . and that's all ? okay . um , so what we're gon na do is i'm gon na give you , um , just continue the motrin at 800mg , three times a day , with food . i want you to use some ice and heat , alternating on your back . but i do want you walking .
[patient] okay .
[doctor] um , and , uh , this should sort of take care of itself after a few days . if it's not , or it's getting worse , i want you to come back and see me over the next week .
[patient] okay .
[doctor] does that sound good ?
[patient] it does .
[doctor] okay , Sarah . hey Sarah , go ahead and order the medications and procedures and close out the note . come on i'll bring you out to check out .
[patient] thank you .

CC:

Back pain.

HPI:

Ms. Lee is a 40-year-old female who presents today for an evaluation of back pain. She states she was at a birthday party and she ran her back into the railing of the staircase and twisted her back. She denies any pain radiating down her legs. Lying flat and twisting motions aggravate the pain. She is currently taking ibuprofen.

CURRENT MEDICATIONS:

Ibuprofen.

PAST MEDICAL HISTORY:

Anxiety.

PAST SURGICAL HISTORY:

Lumbar fusion

EXAM

Examination of the back shows range of motion without pain. Straight leg raise is negative. Sensation is intact.

RESULTS

X-rays of the lumbar spine show no obvious signs of acute fracture. Evidence of a prior lumbar fusion with hardware in good position.

IMPRESSION

Lumbar spine strain.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended ice and heat. She will continue with Motrin 800 mg 3 times a day with food. She will follow up with me as needed.


[doctor] good morning rebecca , nice to see you .
[patient] nice to see you too .
[doctor] so , my nurse told you a little bit about dax , now i'm wondering if i can tell dax a little bit about you .
[patient] go for it .
[doctor] okay , so rebecca is a 27-year-old female patient . um , you have a history of carpal tunnel , um , uh , release done couple of years ago , you have some chronic back pain , some depression . why am i seeing you today ?
[patient] so last week , um , and over the course of the month , i have taken up swimming more regularly .
[doctor] okay .
[patient] i've been trying to get up and get active . and i've- ... all of a sudden i've been feeling some really bad , um , knee pain-
[doctor] okay .
[patient] . in my right knee .
[doctor] just in your right knee ?
[patient] yeah .
[doctor] okay . just when swimming ? are you swimming freestyle with your legs kicking straight or more like breaststroke where your legs kick out ?
[patient] yeah , it's only while swimming. i use the breaststroke so i guess where the legs are kicking out like a frog ... it kinda starts hurting a little bit after i swim a couple laps , which a month ago when i started i was able to do ten .
[doctor] okay .
[patient] but after a couple of laps it starts to hurt .
[doctor] and no injury ? like you did n't fall or twist it or anything like that that you remember ?
[patient] no , not that i can remember .
[doctor] okay . so just swimming a lot and you feeling more and more discomfort ?
[patient] yeah .
[doctor] okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ?
[patient] yeah , it comes and goes , but right now it's been doing really well .
[doctor] okay , no pain going down your legs or anything like that ?
[patient] no .
[doctor] okay . and i know you have some depression , you've been on medication . how's that been going ?
[patient] that's been going really well .
[doctor] okay .
[patient] with the medication and therapy and then trying to get outside more it's been really helping me .
[doctor] sleeping well ?
[patient] yeah .
[doctor] eating well ? okay . do n't feel any concerns about hurting yourself or others or anything like that ?
[patient] no .
[doctor] okay , good . um , and the , you had ca- carpal tunnel done a few years ago . how's that doing ?
[patient] that's doing-
[doctor] any flare up with that ?
[patient] . that's doing really well . i've been getting full range of motion and it's felt a lot better .
[doctor] okay , great . do you mind if i do a quick exam ?
[patient] yeah , go for it .
[doctor] squeeze my fingers for me . good . okay . is it painful if i move your patella like that ?
[patient] yeah , that hurts .
[doctor] okay . and i'm gon na hold your leg out , i'm gon na hold , i want you to stiffen your upper ... does that hurt when i do that ?
[patient] yeah , that hurts too .
[doctor] okay , good , all right . um , let's take a quick look at your x-ray , okay ?
[patient] okay .
[doctor] hey Sarah , show me the right knee x-ray . okay , so here's a picture of your right knee . actually normal x-ray , everything looks good , okay ? on my exam , um , you do n't really have any swelling in- in your joints , um , uh , of your knee . you have a little pain with , um , uh , range of motion of the knee . you have real pain when we do what we call patella in- ... patellar inhibition , okay ? so that's what caused most of that pain . so , um , your heart is regular , your lungs are clear , i do n't feel any adenopathy , your thyroid's , um , normal , your grips are equal , the rest of your exam is essentially normal , okay ? so my assessment is , you have what we call chondromalacia of the patella , okay ? it's just from the overuse and all- all the swimming you've been doing , okay ? so , um , to treat that we'll just use some anti-inflammatories , um , go ahead and take some ibuprofen , 600 milligrams four times a day with food . i do want you to do some straight leg raising exercises , that'll strengthen your quadriceps and that'll help with that pain , okay ?
[patient] okay .
[doctor] um , basically you want to avoid anything that puts extra pressure on your knees for a little while and it should be fine . if it's not getting any better in a couple weeks i wan na see you again , okay ? so no lunges , avoid the breaststroke . if you're comfortable, you can also do other swimming strokes where your knees are straight instead . or you can take the opportunity to have a little break .
[patient] all right .
[doctor] your second problem is your chronic back pain , that's been doing really well . um , keep swimming , that's okay after this gets better .
[patient] yeah .
[doctor] um , but i think , um , i think that's been under control . but if it flares up go ahead and , uh , give me a call , okay ?
[patient] mm-hmm .
[doctor] um , your third problem is your depression . that's been stable . we're gon na keep you on your current medication , not gon na change anything at this point , okay ? and as far as your carpal tunnel goes , that's relatively stable , so , um , uh , no changes there as well . okay ? so anything else i can do for you ?
[patient] no , that's it .
[doctor] okay , well we'll get you checked out .
[patient] all right .
[doctor] hey Sarah , finalize the report .

CHIEF COMPLAINT

Joint pain

HISTORY OF PRESENT ILLNESS

Ms. Thompson is a 27 y.o. female with a history of carpal tunnel release done a couple years ago, chronic back pain, and depression. She presents today for joint pain.

Ms. Thompson reports that over the course of the month she has begun swimming more regularly and trying to be more active. She has experienced bad right knee pain. The patient reports that her knee starts hurting after a couple of laps. She notes previously she could swim 10 laps. She denies injury or trauma to the knee.

The patient has a history of chronic back pain that has been intermittent, but right now it has been doing well. She denies pain radiating down her legs.

The patient has a history of depression, which has been going really well with medication and therapy. She is trying to get outside more and it has been helping her with her depression. She notes she is sleeping and eating well. She denies concerns about hurting herself or others.

The patient's carpal tunnel is doing really well. She has been getting full range of motion and it has felt a lot better.

REVIEW OF SYSTEMS

• Musculoskeletal: Endorses right knee joint pain. Endorses chronic back pain.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Neurological/Psychological: Appropriate mood and affect. Grips are equal bilaterally.
• Neck: Supple without thyromegaly or cervical lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.
• Musculoskeletal: No lower extremity edema. Pain with patellar inhibition. Pain with range of motion of the right knee.

RESULTS

X-ray of the right knee is unremarkable.

ASSESSMENT AND PLAN

Ms. Thompson is a 27 y.o. female who presents today for evaluation of right knee pain.

Chondromalacia of right patella.
• Medical Reasoning: She has been more active lately but is unaware of any injury to the knee. Her recent x-rays were normal but she did have some discomfort on exam.
• Medical Treatment: Prescribed ibuprofen 600 mg 4 times a day with food. I do want her to do some straight leg raising exercises that will strengthen her quadriceps.
• Patient Education and Counseling: I encouraged her to participate in physical activity that is less straining on her joints , such as swimming freestyle laps, or to stop activity all together. If her pain does not improve in a couple of weeks, she will follow up.

Chronic back pain.
• Medical Reasoning: This is stable and well-controlled at this time.
• Medical Treatment: She should continue swimming regularly once her knee is feeling better.

Depression.
• Medical Reasoning: She is doing well with her current regimen.
• Medical Treatment: Continue current medications.

Carpal tunnel syndrome.
• Medical Reasoning: Relatively stable status post carpal tunnel release.
• Medical Treatment: Continue current regimen with no changes at this time.

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


[doctor] we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ?
[patient] i'm good . how are you ?
[doctor] i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ?
[patient] okay .
[doctor] all right . so , michelle is a 31-year-old female with a past medical history of type 2 diabetes and hypertension who presents with abnormal lab finding . so , michelle , it came back to me that you had had a positive long ... lyme titer .
[patient] yeah .
[doctor] and so , uh , can you , you , you know , can you tell me a little bit about it ? i know the last time i saw you , you had had an insect bite , and you know , it came back positive for lyme . so how are you feeling ?
[patient] i've been feeling ... i could feel better . um ... i've been feeling tired , um , really lacking a lot of energy , and i have swollen joints in my elbows , just really hurts .
[doctor] okay . all right . and have you had any , any body aches ?
[patient] yeah , i have .
[doctor] okay . all right . um , and i know that you were out hiking in the woods and , and that type of thing a couple of weeks ago , and we thought that that's where you got the bite . so , um , how's your , how's your appetite ? have you been okay ? a little nauseous ?
[patient] yeah , i've been a little nauseous . i have n't been able to eat much . i've been trying just to keep , you know , toast and crackers and that's all about i've been able to stomach , really .
[doctor] okay , and , and i know that you had had that , that , uh , bite there . have you noticed any other rash anywhere else ?
[patient] yeah , i have .
[doctor] okay . all right . sometimes they kind of describe it as looking as like a bull's-eye .
[patient] yes .
[doctor] is that what it looked like ?
[patient] mm-hmm .
[doctor] okay . all right . well , um , have you had any , any high fevers ?
[patient] uh , no , not that i've noticed .
[doctor] all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?
[patient] they've been okay . i've noticed that they sometimes get a little high and a little low . um , but nothing too far out of range .
[doctor] okay . all right . um , and you're still taking the metformin ?
[patient] yes .
[doctor] okay . all right . good . and then in terms of your high blood pressure , are you monitoring the blood pressures at home ?
[patient] yeah , i , i have a ... i bought a cuff last year , and i've been , um , taking it myself at home . those have looked good . i've been staying away from the salty foods .
[doctor] mm-hmm .
[patient] um , so that's been good .
[doctor] okay . and , um , so you're still taking the lisinopril ?
[patient] yes .
[doctor] okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ?
[patient] no , nothing like that .
[doctor] okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam .
[patient] okay .
[doctor] hey , Sarah , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ?
[patient] okay .
[doctor] okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ?
[patient] yeah , it does .
[doctor] okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ?
[patient] no , no pain for that .
[doctor] non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ?
[patient] okay .
[doctor] so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ?
[patient] okay .
[doctor] i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ?
[patient] okay .
so for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ?
[patient] okay .
[doctor] hey , Sarah , order a hemoglobin a1c . and for your last problem , your high blood pressure . it looks today like everything is fine . i think you're doing a really good job of managing your hypertension , and i'm going to continue you on the lisinopril , 10 milligrams a day , and i'm gon na go ahead and order a lipid panel , and , um , i want you to continue to record your blood , blood pressure regularly , okay ?
[patient] okay .
[doctor] all right . do you need a refill of that ?
[patient] uh , yes , i do .
[doctor] okay . hey , Sarah , order lisinopril , 10 milligrams daily . do you have any questions ?
[patient] no , i do n't .
[doctor] okay , so i'm gon na , you know , the nurse is gon na come in , and she's gon na check you out , and then we'll make a follow-up appointment for you , okay ?
[patient] okay .
[doctor] hey , Sarah , finalize the note .

CHIEF COMPLAINT

Abnormal labs.

HISTORY OF PRESENT ILLNESS

The patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs. She had an insect bite at her last visit after hiking in the woods. We drew a Lyme titer which came back positive.

The patient reports she has been feeling tired and lacking a lot of energy. She also notes swollen elbow joints, body aches, bullseye rash, and nausea. She states she has not been able to eat much. What she does eat has been bland foods such as crackers. She denies any high fevers.

Regarding her type 2 diabetes, she states her blood sugars have been okay. She notes they are sometimes a little high or low, but nothing too far out of range. She is still taking metformin.

Regarding her hypertension, she is monitoring her blood pressure at home and it has been good. She is avoiding salty foods and is still taking lisinopril.

The patient denies abdominal pain and diarrhea.

REVIEW OF SYSTEMS

• Constitutional: Denies fevers. Endorses fatigue.
• Gastrointestinal: Denies abdominal pain and diarrhea. Endorses nausea.
• Musculoskeletal: Endorses bilateral elbow joint swelling, pain. Endorses body aches.
• Integumentary: Endorses a rash.

PHYSICAL EXAMINATION

• Gastrointestinal: Examination of her abdomen reveals warmth to palpation. Nontender to palpation. No evidence of cellulitis.
• Musculoskeletal: Swelling and pain to palpation of elbow joints bilaterally.
• Integumentary: Small bullseye rash on the left abdominal quadrant.

RESULTS

Lyme titer: elevated.

Labs: WBC is within normal limits. All other labs are normal as well.

ASSESSMENT AND PLAN

The patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs.

Newly diagnosed Lyme disease.
• Medical Reasoning: This is a new issue for her. She presented with an insect bite at her last visit, and her subsequent lyme titer was elevated.
• Medical Treatment: I am going to prescribe doxycycline 100 mg twice a day for 3 weeks. I am going to touch base with an infectious disease doctor to ensure nothing else that needs to be done. I want to see her again next week for follow-up for this.

Hypertension.
• Medical Reasoning: This has been well-controlled based on home monitoring. She has been compliant with dietary modifications including limiting her sodium intake.
• Additional Testing: I am going to order a lipid panel.
• Medical Treatment: She will continue lisinopril 10 mg a day. This was refilled today.
• Patient Education and Counseling: I advised the patient to continue to regularly monitor her blood pressures at home.

Diabetes type 2.
• Medical Reasoning: She has noticed intermittent elevations of her blood glucose levels but has been compliant with the use of metformin. Her diet has been limited due to nausea in the setting of Lyme disease.
• Additional Testing: I am going to order a hemoglobin A1c to ensure no medication changes are needed.

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


[patient] um , i have high blood sugar . yeah , osteoarthritis , arterial fibrillation , and reflux .
[doctor] hi , hannah . how are you ?
[patient] good , how are you ?
[doctor] i'm good . you ready to get started ?
[patient] yes , i am .
[doctor] so , hannah is a , uh , 52-year-old female here for evaluation of a high blood sugar . so , hannah , what ha- what happened ? i heard you were in the emergency room with a high blood sugar .
[patient] yes . so , i've been eating a ton of sweets recently . with the holidays it just feels like there is always something sweet available. whether i am at work and there are holiday gift baskets or clients bringing in treats or when i visit my family for the holidays and there is every baked good imaginable, there is always something sweet i can be eating. in the beginning i felt fine, but i have started to feel it after a couple of weeks, and this past week i just felt really light-headed and i could ... was seeing spots , really dizzy . so i went into the emergency room and they said i had a high blood sugar . um , so i wanted to come in and follow up with you to get that , um , get checked out .
[doctor] okay . all right . and how , how are you feeling now ? did they , did , did they treat you in the emergency room ? did they gi- they give you some iv fluids and things like that ?
[patient] yeah . they gave me some fluids and they told me just to try to really cut out eating any extra sweets and get back into my normal routine and diet, but i am still staying with my family, and my mom and grandmother are big bakers so i think it will be really hard to get into a routine there so i just want to make sure i am nipping this high blood sugar thing in the bud.
[doctor] okay . and i saw you went through a review of systems sheet with a nurse . i just want to ask you a few more questions from that standpoint . so you have had any fever or chills ?
[patient] no .
[doctor] any chest pain or shortness of breath ?
[patient] n- uh , no .
[doctor] abdominal pain ?
[patient] no .
[doctor] any burning when you urinate ?
[patient] no .
[doctor] any joint pain or muscle aches ?
[patient] no .
[doctor] okay .
[patient] i do have osteoarthritis though , so that , when i say , " no , " it's not , like , nothing out of the norm-
[doctor] okay .
[patient] . for me .
[doctor] perfect . um , and then , i know that you have this history of a-fib , atrial fibrillation . have you felt your heart racing at all , recently ?
[patient] only when i'm really anxious . i , i feel it , um , pumping a little bit . but other than that i have n't .
[doctor] okay . all right . and how are you doing with your reflux ?
[patient] i've been doing well . i've been taking the medication that you prescribed to me and that's been helping a lot .
[doctor] okay , yeah . i see here you're on the protonix , 40 milligrams , once a day .
[patient] yes .
[doctor] so that's , you're doing well with that ?
[patient] yep .
[doctor] okay . all right . so let's go ahead and do a quick physical exam . so , listening to you , um , look , or looking at you , you appear in no distress . your thyroid is a little enlarged , but non-tender . there's no carotid bruits , your heart is in irregular rate and rhythm , and your lungs are clear . your abdomen is nice and soft , and you have no edema in your lower extremities . let's go ahead and look at some of your test results .
[patient] okay .
[doctor] hey , Sarah ? show me the blood sugar . hey , Sarah ? show me the blood glucose . hey , Sarah ? show me the hemoglobin a1c . okay , so i see here that both your blood sugar and your hemoglobin a1c are elevated . so your blood sugars have probably been running high for probably a few months . okay ? um , let's go ahead and look at some of your other results . hey , Sarah ? show me the diabetes labs . yeah . okay . yeah , so , um , my impression of you at this time , um , for your high blood sugars , that you do have this diagnosis of diabetes . now , we're not sure if it's type i or type ii . even patients in , you know , in their mid-twenties can develop type i diabetes , so we're gon na go off and , we're gon na go ahead and , and send some labs to work that up . hey , Sarah ? order a complete metabolic panel . and i'd like to start you on metformin , 500 milligrams , twice a day . that will help keep your blood sugars down .
[patient] okay .
[doctor] hey , Sarah ? order metformin , 500 milligrams , twice a day . and then if some of the autoimmune labs that come back show that you have an autoimmune disorder , meaning that you would have type i diabetes , then we would have to go ahead and put you on insulin . but i'm gon na hold off until we have those results , okay ?
[patient] okay .
[doctor] but in the meantime , i really want you to avoid , uh , foods high in sugar . um , and the , the nurse will come in and she'll give you a glucometer and teach you how to do blood sugar testing . okay ?
[patient] okay .
[doctor] and then , from an atrial fibrillation standpoint , your heart , even though you're in atrial fibrillation right now , is in a good rate . and we'll just continue you on your metoprolol , 25 milligrams , twice a day . do you need a refill on that ?
[patient] yes , i do .
[doctor] hey , Sarah ? order a refill on metoprolol , 25 milligrams , twice a day . and for your reflux , we'll just continue you on the protonix , okay ?
[patient] okay .
[doctor] do you have any questions , hannah ?
[patient] no , not at this time .
[doctor] okay , so the nurse will come in and she'll go over all that stuff with you .
[patient] okay .
[doctor] take care .
[patient] thank you .
[doctor] hey , Sarah ? finalize the note .

CHIEF COMPLAINT

Evaluation of high blood sugar.

HISTORY OF PRESENT ILLNESS

Ms. Hannah Phillips is a 52-year-old female who presents for evaluation of high blood sugar. The patient admits to dietary indiscretion. She notes that she has been eating more sweets during the holidays. She reports that this past week, she felt really lightheaded, was seeing spots in her vision, and was really dizzy. She went to the emergency room and was told that she had high blood sugar. Ms. Phillips was given IV fluids. The patient was also instructed to get into a routine and watch her diet. She states that she is staying with family during the holidays and having trouble returning to her routine diet, but wants to make sure that her high blood sugar is not an issue.

The patient denies any fever or chills. She denies chest pain or shortness of breath. She denies abdominal pain or burning when she urinates. She denies joint pain or muscle aches.

She notes that she has osteoarthritis, and that nothing seems out of the ordinary for her joint pain.

The patient has a history of atrial fibrillation. She states that she has felt her heart racing when she is anxious; however, other than that, she has not experienced any issues. She is currently taking metoprolol 25 mg 2 times per day.

Regarding her acid reflux, she states that she has been doing well. She has been taking the medication that was prescribed to her, and it has been very helpful. She is on the Protonix 40 mg once daily, and she is doing well with that

REVIEW OF SYSTEMS

• Constitutional: Negative for fever, chills
• Cardiovascular: Negative for chest pain
• Respiratory: Negative for shortness of breath.
• Gastrointestinal: Negative for abdominal pain.
• Genitourinary: No dysuria.
• Musculoskeletal: No Arthralgias, Myalgias.

PHYSICAL EXAMINATION

Constitutional
• General Appearance: appear in no distress.

Neck
• General Examination: Her thyroid is a little enlarged but nontender. There are no carotid bruits. Respiratory
• Auscultation of Lungs: Clear bilaterally. Cardiovascular
• Auscultation of Heart: Irregular rate and rhythm. Musculoskeletal
• Examination of Abdomen: Nice soft and have no edema in lower extremities.

RESULTS

Glucose: elevated.
HbA1c: elevated.

ASSESSMENT AND PLAN

Ms. Hannah Phillips is a 52-year-old female who presents for evaluation of high blood sugar.

Diabetes.
• Medical Reasoning: Elevated blood glucose and hemoglobin A1c levels based on recent labs.
• Additional Testing: We will order a complete metabolic panel for further evaluation.
• Medical Treatment: Initiate metformin 500 mg twice daily. Encouraged dietary modifications. The patient will be given a glucometer to monitor her glucose levels at home.

Atrial Fibrillation.

• Medical Reasoning: Asymptomatic and well-controlled at this time.
• Medical Treatment: Continue metoprolol 25 mg twice daily. Refilled today.

History of Reflux.

• Medical Reasoning: Well-controlled on current regimen.
• Medical Treatment: Continue Protonix 40 mg daily.

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