[doctor] so elizabeth is a 53 -year-old female today complaining of chest pain and she has a past medical history of diabetes and high blood pressure so elizabeth tell me what's going on with your with your chest pain
[patient] i do n't know every time i start walking i'm just having this kind of pressure and chest pain in my chest
[doctor] okay are you having it now or is it gone right now
[patient] right now it's not there
[doctor] okay and how long have you been having this
[patient] probably maybe three months
[doctor] okay and what seemed to bring it on anything exacerbated or relieve it
[patient] it mainly happens when i'm walking i like to try and walk but lately i just have n't been able to keep up with it because i'm having this pain
[doctor] alright and well how would you describe this pain it's like a dull pain sharp pain stabbing pain how would you describe it
[patient] i would say it's dull it's kinda like a pressure
[doctor] okay and does it go anywhere or radiate any place
[patient] no
[doctor] okay alright but no chest pain right now no shortness of breath no sweats or clamminess or anything like that right now
[patient] nothing right now
[doctor] okay alright well certainly you know i looked at your ekg that did we did in the office when you came in the ekg i do n't see any signs of a heart attack or anything like that so i'm you know we should definitely talk about the plan for this chest pain in a few minutes but right now the good news is i do n't see any signs of a heart attack or anything like that so let's talk a little bit about your other conditions since you are here today how are you doing with your diabetes i know we have you on metformin and we talked about last time about you know improving your diet and exercise i'm glad you're exercising but i'm so sorry to hear about the chest pain so tell me about how is that going
[patient] yeah i mean i think my blood sugars have been a little higher because i have n't been able to be active and i'm trying with the diet you know i do love sodas so i'm really trying strength dose
[doctor] yeah i i am addicted to diet coke myself so i i hear you on that one and we had checked your hemoglobin a1c last time it was you know seven . which is pretty good it's not you know it could be better but it's not it's not bad and we talked about sending you to ophthalmology also for an eye exam have you seen ophthalmology in the last few months or last before i saw you
[patient] i have an appointment in two weeks it was a long waiting
[doctor] okay got it and any nausea vomiting or diarrhea or anything like that with your diabetes or any side effects from your medications the metformin
[patient] no
[doctor] okay alright good and i saw also there was a record in your i was looking at your record before previously before i walked in you also had we've been checking your blood pressure but but i think you've been into several other clinicians and they had documented high blood pressure have you noticed any findings with that or have you know have anybody talked about high blood pressure with you or mentioned that because we do n't have it in our system here yet but i did add it in today but we do n't have you on any medications yet for that
[patient] no i mean i do n't know doc no one told me about high blood pressure do i have high blood pressure
[doctor] well i think the last time you were in the clinic and one of the clinics said the referrals the your blood pressure was elevated so they had mentioned that i noticed a trend in your blood pressure it's been running on a little bit on the high side we have n't really diagnosed you with that yet but i think we are something that we should definitely consider looking at your trend of your blood pressure readings over the last you know a few years
[patient] okay do you think that could be causing me my my chest pain
[doctor] it certainly could be contributing to that it certainly could be a factor that we need to look at so
[patient] someone had told me before
[doctor] yeah me too but we we can we can definitely you know get you started on some monitoring devices for that and also maybe start you on some some diet control things that we can do to help with the blood pressure and maybe start you on some blood pressure medications if we need to okay
[patient] okay sounds good
[doctor] so let me examine you elizabeth for a second for the because we're running out of time here for a second so i'm gon na go ahead and do my exam we got ta just did my magical exam and i'm gon na go ahead and verbalize some of my findings just so i can get it documented in my note okay and i'll explain things as we go along so there is no jvd there is no swelling in your neck there's no carotid bruits your lung exam is clear i do n't hear any crackles or rhonchi your heart exam you do have a two over six systolic ejection murmur you had that in the past otherwise it's regular rate and rhythm your pulses are equal your belly exam is nice and soft your no tenderness no guarding no masses that i can feel on your belly and your back exam is fine your extremity exam you have a little bit of swelling in your lower legs one plus nonpitting edema or swelling in the in your in your ankle area here no calf tenderness so what does all this mean i'll explain that in a second so basically your exam is pretty normal except for you have a little bit of swelling in your legs so you know with this chest pain i'm a little bit so the first diagnosis that we talk about is this chest pain i'm worried about my suspicion is you have something called unstable angina especially considering your history of diabetes and the suspected history of high blood pressure and your family history of of heart disease in the past as well i'm i'm gon na go ahead and refer you to cardiology i reviewed your ekg today so that looks normal so that's good no other signs of a heart attack but i am worried that you may have some sort of a blockage going on that's causing this chest pain i'm gon na go ahead and start you on some aspirin daily i'm also gon na give you a prescription just a baby aspirin you can take eighty one milligrams once a day and also i'm gon na give you a prescription for nitroglycerin it's a it's a little pill you split underneath your tongue if you have this chest pain if it does n't go away after one or two pills i want you to go to the hospital call nine one one and go to the hospital but we will try to get you into cardiology the next week and get you set up for some sort of a stress test to look at your heart okay any questions about that
[patient] so anytime i have a chest pain even if i'm just like walking i have to take that pill
[doctor] yeah if you if you stop walking the chest pain goes away you do n't have to take the pill but if you are walking or you stop and the chest pain does not go away i would take the pill and see if it goes away if it does not
[patient] how long like how long do i wait to see if it goes away
[doctor] about five minutes so you can take it up to three pills every five minutes and if it does n't go away then i would you know go to the hospital and get this checked out because i worry about with this chest pain that you're having making sure it does n't lead to a heart attack those chest pain could be a you know a a a sign that you may be having some less blood flow to your heart and we need to get that checked out pretty quickly
[patient] okay
[doctor] alright
[patient] mm-hmm
[doctor] and for the second problem the diabetes you know i think you're doing fairly well continue with your eye ophthalmology appointment you have for your eye exam for the diabetic retinopathy continue the metformin five hundred milligrams twice a day i'm gon na order another hemoglobin a1c today and i'm gon na have you come back in about two weeks and we can see if we need to make any adjustments continue to try to stay away from you know the the pop and the sweet things and once we have your heart taken care of or make sure your heart is okay you can and we can hopefully resolve this chest pain that you're having get back to your exercise regimen okay any questions about that
[patient] no
[doctor] okay and for the third diagnosis the high blood pressure you you do have a trend i've noticed in your chart that your blood pressure's been running a little bit high several other people have documented as well i'm gon na go ahead and start you on some hydrochlorothiazide it's a pretty low dose medication to help you with your blood pressure plus it'll also help with you some of the swelling you have in your in your feet i'm gon na have you use a blood pressure cuff at home and enter your findings at epic mychart and i'll get a reading of those as well and then what when you come back in two weeks we'll keep a log of your blood pressure daily in the morning when you wake up and see how things are going and then if we need to make any adjustments to the medications we can but especially considering your history and the chest pain and the diabetes and the swelling i think starting this hydrochlorothiazide is a probably a good idea
[patient] okay are there any side effects with this medication
[doctor] yeah it can cause sometimes it can cause a little bit of make you go to the bathroom a little bit more often in the evening but generally most people do n't have a whole lot of side effects i'll give you a handout of the side effects but sometimes you can have a cross reaction with some other medications like sulfa medications but generally most people tolerate this pretty well
[patient] okay
[doctor] alright any other questions we got
[patient] that's it
[doctor] alright well great seeing you thanks for coming in today
[patient] thank you appreciate it

CHIEF COMPLAINT

Chest pain on exertion.

MEDICAL HISTORY

The patient has a medical history of diabetes type 2. She has not been formally diagnosed with hypertension, but her blood pressures have been trending high.

FAMILY HISTORY

Patient reports family history of heart disease.

MEDICATIONS

Patient reports taking metformin 500 mg twice daily.

REVIEW OF SYSTEMS

Constitutional: Denies diaphoresis or clamminess.
Cardiovascular: Reports chest pain.
Respiratory: Denies dyspnea.
Gastrointestinal: Denies nausea, vomiting, or diarrhea.

PHYSICAL EXAM

Neck
- General Examination: No JVD, swelling, or carotid bruits.

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

Cardiovascular
- Auscultation of Heart: 2/6 systolic ejection murmur, otherwise normal rate and rhythm. No murmurs, gallops or rubs. Pulses are equal.

Gastrointestinal
- Examination of Abdomen: No masses or tenderness. Soft, no guarding.

Musculoskeletal
- Examination: 1+ nonpitting edema in the ankles. No calf tenderness.

RESULTS

EKG was obtained and reviewed in office today and is unremarkable. Hemoglobin A1c: 7.0

ASSESSMENT AND PLAN

1. Chest pain.
- Medical Reasoning: Considering her history of diabetes, possible history of hypertension, and family history of heart disease, I suspect her chest pain is likely unstable angina. Her recent EKG was unremarkable and there are no other signs of heart attack, but I am worried she may have some sort of a blockage causing her pain.
- Patient Education and Counseling: We discussed proper protocol for sublingual nitroglycerin for chest pain. I advised her to go to the emergency department if the medication is not effective after approximately 5 minutes.
- Medical Treatment: We will have her start a regimen of baby aspirin at 81 mg daily, for which I have sent in a prescription today. I also sent a prescription for nitroglycerin up to 3 tablets every 5 minutes as needed. Finally, I am going to have her follow up with cardiology for further evaluation.

2. Type 2 diabetes.
- Medical Reasoning: She appears to be doing well on her current regimen.
- Patient Education and Counseling: I encouraged the patient to keep her appointment with ophthalmology for evaluation of diabetic retinopathy.
- Medical Treatment: I'm going to put in an order for a repeat hemoglobin A1c to check for any needed medication adjustments and have her follow up in 2 weeks. In the meantime, I want her to continue with metformin 500 mg twice daily and dietary modifications.

3. Hypertension.
- Medical Reasoning: Several providers, including myself, have noted a trend of elevated blood pressures in the patient's chart.
- Patient Education and Counseling: I advised the patient to monitor her blood pressures at home over the next 2 weeks and report her readings to me via MyChart. This should help us determine if any adjustments need to be made to her new medications. We discussed the possible side effects of hydrochlorothiazide how this will hopefully reduce some of her swelling seen on physical exam. All of her questions were answered.
- Medical Treatment: I'm going to have her start hydrochlorothiazide at a low dose.

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

INSTRUCTIONS

The patient will follow up in 2 weeks.


[doctor] hey sophia how are you doing today
[patient] i've been better my primary care doctor wanted me to see you because of this knee pain that i've been having for about six months now
[doctor] okay do you remember what caused the pain initially
[patient] you know i really ca n't recall any specific event that caused the pain
[doctor] alright well can can you describe the pain for me
[patient] yeah so it's it's like a deep achy pain that it i feel like it's behind my kneecaps and sometimes i can even hear like what seems like like some creaking in my knees
[doctor] hmmm alright now tell me what what type of activities makes that pain worse
[patient] so i feel like the pain gets worse anytime i'm like getting from like a seated position to standing so i i work from home so i'm at my desk a lot so anytime i get up i have some pain or after watching tv or even like going up and down stairs it's really painful
[doctor] hmmm okay and does anything make the pain feel better
[patient] usually after i rest it for some time it does help with the pain
[doctor] okay now you did mention earlier that you have tried some things in the past can you tell me what they were
[patient] yeah so when it first started hurting i was putting ice on it and i even got like some ace bandage like wrapping from the pharmacy i do take ibuprofen or aleve sometimes but i try to avoid really taking any medications
[doctor] okay and and tell me what is your day like
[patient] well i try to be as active as i can i actually love to run and i would run like five to six miles a day but now i i mean honestly i ca n't even get to half a mile and my leg will start hurting my knee will start hurting
[doctor] okay that's definitely a decrease in your mileage there where have you been running lately like do you run outside or on a treadmill or
[patient] yeah i i you know i will do the treadmill during the winter but i just love being outdoors and running
[doctor] yeah yeah there are some really nice senior routes here in boston is n't there like
[patient] there are
[doctor] so many knee places there's some right by the harbor that i've i've done some runs there before too it's pretty nice well i mean the boston marathon what can you say right
[patient] right exactly exactly no it's very nice
[doctor] well okay well hopefully that we get you feeling better so you can start running again more than . five miles but tell me though have you noticed any swelling or redness in your knees
[patient] no not really
[doctor] okay and have you ever injured your knees before
[patient] no i've been pretty good i actually have never broken a bone actually no i'm gon na change that actually i did break my arm when i was in sixth grade but nothing since then
[doctor] okay
[patient] i
[doctor] okay and it's just your arm right not not your knee
[patient] right
[doctor] okay well alright well let's go ahead and do a quick physical exam on you here let me look at your vital signs okay i reviewed your vitals they they overall they look good take a listen to your heart real quick alright and your heart exam i hear regular rate and rhythm with no murmurs and on your musculoskeletal exam i have seen you and walk around here and you do have normal gait alright now i'm gon na have you do some movements on your legs here okay
[patient] okay
[doctor] alright good your strength is three out of five for abduction of legs bilaterally and the remainder of muscle strength for your lower extremities are five out of five so that's good let me take a look at your knee now on your knee exam there is no overlying erythema that's redness or ecchymosis and that's bruising or any warmth of the skin appreciated there is no effusion let me go ahead and feel around here does that hurt right here how does that feel
[patient] it does
[doctor] sorry so there is tenderness to palpation of the bilateral retinacular retinaculum and there is positive patellar grind test alright and can you are you able to squat for me
[patient] i can but that hurts
[doctor] okay alright so you're definitely having some knee pain with squatting and i'm just gon na maneuver your leg just a little bit here real quick okay so lachman anterior and posterior drawer and mcmurray tests are all negative bilaterally so that's good there okay now your neuro exam patella and achilles reflexes are symmetrical alright so now i did review the results of your x-ray and both of your knees which shows no fractures or osteoarthritis so let me go ahead and tell you about my assessment and plan so for your problem of bilateral knee pain based on what you told me your exam and reviewing your mri your symptoms are consistent with patellofemoral pain syndrome and this is a very common condition that we see that causes knee pain especially in active young people so this condition has to do with the way your kneecap which is your patella how that moves along the groove of your thigh your thigh bone which is the femur now for the pain you may continue taking ibuprofen or anti-inflammatory as needed to help with the pain but i'm also going to recommend physical therapy where where they will show you a number of lower extremity exercises and this will help increase your lower extremity strength your mobility and correct any incorrect running mechanics that you may have so do you have any questions for me about that
[patient] will i be able to run anytime soon
[doctor] well that is a goal of treatment and to get you back in running again now you will have to take an take it easy from running for now but we will continue to assess your progress with each visit okay
[patient] okay
[doctor] alright anything else
[patient] no i think that's it
[doctor] okay well very good well i will be following up with you soon and again just take it easy for now from the running okay
[patient] okay thank you
[doctor] bye
[patient] bye

CHIEF COMPLAINT

Bilateral knee pain.

HISTORY OF PRESENT ILLNESS

Sophia Jackson is a pleasant 30-year-old female who presents to the clinic today for the evaluation of bilateral knee pain. She was referred by her primary care provider. The onset of her pain began 6 months ago. She denies any specific injury. The patient describes her pain as a deep, achy pain. She locates her pain to the posterior aspect of her patellae. The patient also reports “creaking” in her knees. She denies any swelling or redness in her knees. Her pain is aggravated by transitioning from a seated position to standing as well as ascending and descending stairs. Her pain is alleviated by rest. The patient has been icing her knees and wrapping her knees with an ACE bandage. She also takes ibuprofen or Aleve occasionally for pain. She states she tries to be as active as she can. She enjoys running outdoors. The patient adds that she would run 5 to 6 miles per day; however, she is unable to go 0.5 miles secondary to the pain. She denies any previous injuries to her knees.

She works from home.

MEDICAL HISTORY

Patient reports history of an upper extremity fracture when she was in 6th grade.

REVIEW OF SYSTEMS

Musculoskeletal: Reports bilateral knee pain and crepitus. Denies swelling or redness in the bilateral knees.

VITALS

All vital signs are within the normal limits.

PHYSICAL EXAM

GAIT: Normal, no deformity present.
CV: Auscultation of Heart: Regular rate and rhythm. No murmurs.
No edema
NEURO: Patella and Achilles reflexes are symmetrical.
MSK: Examination of the bilateral lower extremities: Abduction strength is 3/5. Remainder of muscle strength is 5/5. Examination of the bilateral knees: No overlying erythema, ecchymosis, or warmth of the skin appreciated. No effusion. Tenderness to palpation of the bilateral retinaculum. Positive patellar grind test. Knee pain with squatting. Negative Lachman test bilaterally. Negative anterior and posterior drawer tests bilaterally. Negative McMurray test bilaterally.

RESULTS

X-rays of the bilateral knees were reviewed today. These demonstrate no evidence of any fractures or osteoarthritis.

ASSESSMENT

Bilateral knee patellofemoral pain syndrome.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient regarding her current symptoms. I have explained to her that her symptoms are consistent with patellofemoral pain syndrome. We discussed treatment options and I have recommended that we begin with conservative treatment in the form of formal physical therapy to increase her lower extremity strength, mobility, and correct any incorrect running mechanics. I encouraged her to take running easy for now. She can continue taking ibuprofen or anti-inflammatories as needed for pain. All questions were answered.

INSTRUCTIONS

The patient will follow up with me soon.


[doctor] hey kyle so i see here on your chart that you've been having some back pain could you tell me like how you've been doing what's going on
[patient] yeah i have this real bad low back pain it started a couple of weeks ago i was lifting something and i just felt a pop and i i do n't know what's going on
[doctor] okay and so you were like moving what what were you moving exactly when you say lifting
[patient] i was lifting a box of books
[doctor] okay
[patient] yeah
[doctor] alright did we use proper lifting technique do you wonder
[patient] you know probably not
[doctor] okay alright i'm sorry about that alright can you describe the pain for me
[patient] yeah i i feel like kind of it's like achy and sharp
[doctor] oh
[patient] in in my low back
[doctor] uh uh and does the pain like radiate anywhere
[patient] you know it did n't at first but now i'm feeling it's kinda starting to shoot down my left leg
[doctor] okay alright and how is positioning for you does any sitting in any particular position hurt more or hurt less
[patient] no sitting is usually okay for me
[doctor] mm-hmm okay and then do you have any numbness or tingling associated with the pain
[patient] no
[doctor] okay alright any loss of sensation
[patient] no
[doctor] okay how yes sir okay how about any weakness
[patient] no i do n't feel any weakness
[doctor] okay and i know this sounds like a weird question but i do need to know do you experience any loss of control of your bladder or bowels
[patient] no
[doctor] alright this this is a no judgment zone i there i'm working through some things in my head to make sure that i give you the best care that we need right i'm making a plan as we move along you mentioned that the pain has been getting worse have you done anything or tried anything that's worked in the past
[patient] i tried to take some ibuprofen and tylenol
[doctor] mm-hmm
[patient] that that sometimes helps
[doctor] okay alright and has anyone discussed the option of like just no has anyone discussed surgery with you
[patient] no this is the first time i'm talking about it
[doctor] okay alright that's good so what is your like how what is your activity level right now that i know that you're you know an olympic weightlifter with books what else do you do to like exercise
[patient] you know i try to exercise a few times a week but i'm pretty inconsistent i have a sedentary job
[doctor] okay alright and has this like pain started to like affect you like in your job or anything like that
[patient] not my job but i feel like i do n't want to be as active as i was previously
[doctor] alright so do you have any family members that have spine conditions
[patient] yeah my dad has back pain
[doctor] okay alright and then do you smoke
[patient] i do n't smoke
[doctor] okay awesome alright so sorry one question did you do you have a history of playing sports
[patient] yes
[doctor] okay what did you play
[patient] soccer
[doctor] okay what position
[patient] i played midfield
[doctor] okay the people who hide in the back that's fine i was centered forward fine no baby do you have a team that you wrote for
[patient] you know i am a tatnham hotsper fan
[doctor] they have the best colors not going to lie but i i grew up manu so sorry
[patient] well i wo n't fault you for that
[doctor] thanks okay so if you do n't mind i'm gon na go ahead and do my physical exam i'm gon na call out my findings just to have them recorded and if you have any questions please feel free to stop me and let me know okay
[patient] okay
[doctor] alright so looking at your vitals your blood pressure seems alright we are in like the one thirty over seventy range that's perfectly fine your respiratory rate i have you at an eighteen again pretty normal when i listen here to your heart you have a regular rate and rhythm i do n't appreciate any murmurs rubs or gallops that means your heart sounds great on your respiratory exam your lungs sound clear to auscultation bilaterally on your musculoskeletal back exam as i'm looking here i do n't notice any overlying redness or bruising on the skin when i push here on the midline of your back does it hurt
[patient] yes
[doctor] okay so there is midline tenderness at the l4 l5 disk space with right sided lumbar paravertebral tenderness alright so are you able to bend forward
[patient] yes
[doctor] alright and are you able to bend backward
[patient] yes
[doctor] alright do either of those actions cause you pain
[patient] bending forward
[doctor] okay so pain with lumbar flexion and so i'm gon na have you lie down and we're gon na do i'm sorry okay and then i see that a supine straight leg test is positive alright so for your neurological exam you said that you are experiencing pain radiating down radiating down your left leg correct
[patient] yes
[doctor] alright when i touch are there any like decreased sensation
[patient] no
[doctor] okay alright so patella and achilles reflexes are symmetrical alright so i received before you came in here we got an mri and so in reviewing your results it does show a disk desiccation a disk bulge with paracentral disk herniation resulting in moderate right neuroforaminal i do n't like this word neural foraminal stenosis what those complicated words is that i just said is that it seems that you have a a a herniated disk with nerve impingement so let's talk about my assessment and plan alright your symptoms are in line with a i'm sorry you have lumbar back pain at the l4 l5 disk space due to a herniated disk with radiculopathy this means that one of your disks that sits between your vertebrae like the bones in your spine is bulging out and the bulge is pinching on some nerves so that's why you are feeling that pain like radiating down your leg i'm gon na recommend something a spinal injection with a strong nsaid and called the i'm sorry and a corticosteroid i'm just gon na inject it into the lumbar spine under fluoroscopy which you can think of like an x-ray to localize the exact area of your pain this should help with the inflammation that's causing your pain i know that sounds a bit scary it this is a typical procedure that i do all the time it's in office and we can get you scheduled today if you would like so what questions do you have right now
[patient] is that something that we can do today
[doctor] yeah i think i have time in my schedule to get it done today just you know i'm here for you right now
[patient] alright
[doctor] okay
[patient] are there are there any complications with this
[doctor] there are sorry yeah you're right there are risks associated with this kind of injection just like any procedure but we aim to minimize them and my ma when she comes in we will give you some paperwork with explanations and any and hopefully answer most of the questions that you have if after reading that you have any more questions please feel free to stop us we want to make sure that you feel as comfortable as possible during this time
[patient] okay
[doctor] alright
[patient] great
[doctor] anything else
[patient] i think that's it
[doctor] alright

HISTORY OF PRESENT ILLNESS

Kyle Morales is a pleasant 58-year-old male who presents to the clinic today for the evaluation of low back pain.

Onset of his pain began 2 weeks ago, when he was lifting a box of books and felt a pop. The pain is described as aching and sharp. His pain has been increasing since the time of onset and is beginning to radiate down his left leg. The patient denies any pain with sitting. He adds that he has a sedentary job. The patient states that his pain does not affect his job, however he feels that he does not want to be as active as he was previously. He tries to exercise a few times per week, however he is inconsistent. He denies any numbness, tingling, loss of sensation, weakness, and loss of control of his bladder or bowels.

The patient has been taking ibuprofen and Tylenol for pain, which provides some relief. He has not been evaluated for surgery.

SOCIAL HISTORY

He denies smoking. The patient has a history of playing soccer in the midfield position.

FAMILY HISTORY

The patient states that his father has back pain.

REVIEW OF SYSTEMS

Musculoskeletal: Reports low back pain.
Neurological: Denies bowl or bladder control issues, numbness, tingling, decreased sensations, or weakness.

VITALS

Blood pressure: 130/70 mm Hg.
Respiratory rate: 18.

PHYSICAL EXAM

CV: I do not appreciate any murmurs, rubs, or gallops.
RESPIRATORY: Normal respiratory effort no respiratory distress. Clear to auscultation, bilaterally.
BACK: No evidence of trauma or deformity
NEURO: Normal sensation. Patellar and Achilles reflexes are symmetrical.
MSK: Examination of the lumbar spine: No ecchymosis noted. Midline tenderness at the L4-5 disc space with right-sided lumbar paravertebral tenderness. Pain with lumbar flexion. Positive supine straight leg test.

RESULTS

The MRI of the lumbar spine was reviewed today. It revealed disc desiccation and a disc bulge with a paracentral disc herniation resulting in moderate right neural foraminal stenosis.

ASSESSMENT

Lumbar back pain at the L4-5 disc space due to a herniated disc with radiculopathy.

PLAN

After reviewing the patient's examination and MRI findings today, I have discussed with the patient that his MRI revealed a herniated disc with radiculopathy. We discussed treatment options for this and I have recommended that we begin with conservative treatment in the form of a corticosteroid injection. With the patient's consent, we will proceed with a corticosteroid injection into the lumbar spine today. The patient was made aware of the risks of bleeding, infection, nerve damage, blood vessel damage, reaction to the medication, including skin changes, swelling, and also, the risk of elevated glucose levels if the patient were diabetic.


[doctor] angela good to see you today so i'm writing here in my notes that you're you're coming in you had some left knee pain so how did you hurt your knee
[patient] yeah so i hurt my knee the other day when i was running around with my niece she she is learning how to take off the training wheels for her bike
[doctor] mm-hmm
[patient] and i fell and i think i twisted my knee in some kind of funky way
[doctor] okay that that that that's not good how old are your niece
[patient] she is five and perfect
[doctor] well that's good that you're trying to help her with the learning how to ride a bike
[patient] yeah
[doctor] that sounds fun but i'm i'm sad as you hurt your knee doing it so for your knee pain are you are you able to bear weight on that leg the left leg
[patient] well i've been limping ever since and it really has n't gotten better so i thought it was maybe time to come see you because it happened about a week ago
[doctor] yeah yeah it's a definitely a good time to come see me so what part of your knee would you say it hurts
[patient] honestly it's been hurting on both sides more so on the inside than the the outside
[doctor] so okay so more in the medial aspect less on the lateral okay that makes sense and you said did you hear a pop when you when you twisted it
[patient] yeah i did
[doctor] okay alright so how would you rate your pain with your knee out of out of one to ten
[patient] it started off as like a four but i think it's getting worse and it's starting like it's it's like a like a throbbing kind of pain yeah
[doctor] alright and have you taken anything for the pain
[patient] yeah so i i had like a ulcer not too long ago so my doctor told me that i could n't take any like kind of advil or ibuprofen
[doctor] mm-hmm
[patient] so i've been taking some tylenol and i wrapped it with kinesiology tape are you familiar with that
[doctor] yep yeah i'm i'm familiar
[patient] okay
[doctor] alright and has the has the ibuprofen been helping you at all
[patient] i ca n't take ibuprofen
[doctor] i mean i'm sorry the tylenol
[patient] no it's okay but the tylenol it helps like a little bit but you know like it's it's got like a time limit right so by the time and i'm not supposed to take it like more than like every like four hours or something like that but by hour or two like it it hurts again
[doctor] okay yeah that yeah you ca n't take too much of that tylenol because it'll it'll mess up your liver definitely
[patient] right
[doctor] alright so go ahead and do a quick exam on your knee here so when i press here does that hurt
[patient] yeah like when you press on the inside that hurts a lot
[doctor] okay alright i'm gon na do a couple of other other maneuvers here for your knee so on your left knee exam i do appreciate some edema you also have some effusion some fluid in the knee you have moderate range of motion so you're able to move it a little bit but not all the way i also see you have some pain on flexion and extension of the knee even negative lachman's test and a negative valgus and varus test as well so all that to say is i do n't think anything is is torn in your knee based on the your physical exam so we did do a x-ray of your left knee and luckily it was normal so there is no fractures no bony abnormalities so everything is good there so let me talk to you little bit about my assessment and plan for your knee okay
[patient] yeah
[doctor] alright so for your your left knee pain i believe you you have a mcl strain or a medial collateral ligament that's the inside of your knee i think when you were running with your knee she had somehow twisted it and so you strained that ligament there so for that what i want to do i'm going to give you some pain medication that's not an nsaid so i will put you on some tramadol you can take fifty milligrams you can do that twice a day and then you can take that tylenol as needed for breakthrough pain alright i'm gon na put you in a knee immobilizer leg knee immobilizer and you can wear that for the next week i just wan na keep the knee from moving so it can heal a little bit and reduce some of the inflammation that you're seeing here and i also want you to ice it and you can do that three or four times a day for twenty thirty minutes at a time and that should help some of that swelling as well and i i you know i know your niece is gon na be upset but i just do n't want you to be running probably for the next three weeks with her just to help us get time to let allow the knee to heal so how does that sound
[patient] that's alright how long do you think it'll be before i can like run or something like that
[doctor] hmmm i think you'll be back to normal in about a month the strain does n't seem too bad but we just need to get you off of the knee so we can allow it to heal i mean once we do that you know along with you know the icing the mobilization and you taking the medication i think you'll be good to go in a month if you do feel like you're getting a little bit worse please feel free to call the office and we can get you in and possibly do more imaging such as an mri to you know to see if it's anything worse but i do n't think it is but just let us know how you feel in a couple of days
[patient] okay alright thanks
[doctor] alright any other questions
[patient] no that's it
[doctor] alright great thanks

HISTORY OF PRESENT ILLNESS

Angela Powell is a pleasant 81-year-old female who presents to the clinic today for the evaluation of left knee pain. The onset of her pain began 1 week ago, when she was running around with her niece and fell. At the time of the injury, she heard a pop and believes that she twisted her knee. She reports that she has been limping since the injury. The patient locates her pain to the medial and lateral aspects of her knee. She rates her pain level as a 4 out of 10, however this is increasing. Her pain is described as a throbbing pain. The patient has been taking Tylenol, which has provided mild and temporary relief, as well as wrapping her knee with kinesiology tape. She states that she is unable to take ibuprofen secondary to an ulcer.

PHYSICAL EXAM

MSK: Examination of the left knee: Edema and effusion noted. Moderate ROM. Pain with flexion and extension of the knee. Negative Lachman's. Negative valgus and varus stress test.

RESULTS

4 views of the left knee were taken. These reveal no evidence of any fractures or dislocations. No other abnormalities are noted.

ASSESSMENT

Left knee pain, possible MCL strain.

PLAN

After reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays did not reveal any signs of a tear. I have recommended that we treat the patient conservatively. The plan is to place the patient in a knee immobilizer to provide increased support for the next week. I have also prescribed the patient tramadol 50 mg to treat her pain. She can take Tylenol as needed for breakthrough pain. I have also advised her to ice her left knee 3 to 4 times a day for 20 to 30 minutes at a time. I have advised her to refrain from running for the next 3 weeks. If her pain does not improve with the immobilizer, I will recommend obtaining an MRI.


[doctor] next patient is christine hernandez . date of birth is january 13 , 1982 . hey miss christine , how are you doing today ? [patient] i'm good , thanks , how are you ? [doctor] i'm pretty good . so it looks like you've completed the covid vaccine , that's great . [patient] yes , i did . [doctor] anything new since your last visit ? [patient] no , i did all the tests that you had recommended me to take . i have n't been able to take the thyroid medicine . the one that you prescribed as i'm still taking my old one , the price is a little high on the new one . [doctor] okay , so did , did you try the coupon that i gave you ? [patient] i did not try the coupon . there was a charge of $ 75 . [doctor] okay , well , next time that , that coupon should help , but it should only be about three dollars . [patient] okay . i do n't have it . do you happen to have another one you can give me ? [doctor] yep , right here . [patient] wonderful . thank you so much and and then the gel they are charging me $ 100 for it , so i do n't know if this is because it's a , it's walmart or if i should try somewhere else or maybe you know how or where i could get it cheaper . [doctor] yeah , let's try something else . sometimes it can be cheaper if we just prescribe you the individual ingredients of a medication rather than the , the combined medication itself . [patient] that would be great . [doctor] so that's clindamycin gel and benzoyl peroxide maybe by doing them separately , they could be a lot cheaper so that we can do , the unithroid with the discount code should only be about nine dollars for 90 days . [patient] okay , that would be great , yeah , they were charging me $ 75 and i just could n't pay that . [doctor] maybe we try a different pharmacy as well . [patient] okay . so do you think that my weight gain could have been the birth control that i was taking before that caused it ? [doctor] maybe . i do n't really see an endocrine cause for it at least , so i would need to see the , the hyper and dragonism or high testosterone or a high dhea to cause acne or hair growth or any of that stuff , but the numbers are n't showing up out of range . [patient] okay . [doctor] i really do n't see any endocrine cause for it , like i said , your growth hormone was fine , but we definitely want to and need to treat it i do n't know if we talked about maybe a little weight loss study . [patient] you mentioned the weight loss study and you mentioned that i have some meal plans that you had given me , i still have those two . [doctor] have you tried to make any changes in the diet since the last time we spoke ? [patient] i've been trying to get better . i will start back at the gym in july because of my contract , i had to put a hold on it until then . [doctor] okay . [patient] so i do want to start doing that . i will be a little freeer since i'll be on vacation after july 8 . [doctor] okay , good . [patient] and then my cousin was telling me to ask you about cla because it's supposed to help your metabolism , is that okay to take ? [doctor] i'm not sure , what is the cla ? [patient] i'm not sure what it is either . [doctor] okay , well , i'm unfamiliar with it , so . [patient] okay . i also have a coworker who has a thyroid issue too and she suggested to try chromium for weight loss . [doctor] so that likely will not help too much . you could try it either if you really want to but then they will not accept you into the weight loss study if you try those two . [patient] okay . [doctor] chromium is just a supplement and it wo n't help that much . [patient] it wo n't , okay , thank you . [doctor] it wo n't hurt like i should n't say that it wo n't hurt , but it also wo n't help that much , so it's up to you . [patient] okay and so my cousin also suggested amino acids and that i might find them in certain foods i guess for my workout . [doctor] yeah , amino acids are fine , they wo n't , wo n't really help with weight loss either , but it might help you replenish and just kind of feel hydrated . [patient] okay , are they proteins , my cousin said she had lost some weight and has been working out every day but she does n't work , so i do n't know . [doctor] yes , i mean acids are what make up the protein , which is in any food you eat with any protein , so meat , dairy , nuts , any of that sort of thing . [patient] okay , thank you , got it . [doctor] alright are you allergic to any medications ? [patient] no , not that i know of . [doctor] okay . is your skin pretty sensitive ? [patient] yes . [doctor] alright . [patient] yeah , on my sides , i will start getting rashes with different products . [doctor] and have you ever tried clindamycin topical as an antibiotic for your acne ? [patient] no , i've never tried anything for it . [doctor] okay . we may give you some of that . [patient] okay and i also want to mention that my feet do swell up a lot . [doctor] okay . i'm , i'm gon na take a look at that for just a moment . any constipation ? [patient] yes , i also do have that problem . [doctor] alright . miralax will definitely help with that . [patient] okay , yes , my doctor did also recommend that . [doctor] great . alright , let's do an exam real quick . please have a seat on this table and i'm gon na listen to your lungs and heart . [patient] okay . [doctor] alright . deep breath , alright again . [patient] okay . [doctor] alright sounds good . [patient] great . [doctor] let me take a look at your feet and ankles . [patient] okay . [doctor] alright , they look okay right now . certainly let your doctor know about this if it gets any worse or reoccurs . [patient] okay , i'll do that . [doctor] now let's go over your lab work . so when you took that pill , the dexamethasone test , you passed , which means you do n't have cushing syndrome on that test at least . the salivary cortisol though unless you did one wrong , two of them were completely normal , one was abnormal , so we might need to repeat that in the future . [patient] okay , that's okay . [doctor] alright , so your cholesterol was quite high , the total cholesterol was 222 , good cholesterol was about 44 , the bad was 153 and it should be less than 100 . the non-hdl was about 178 and it should be less than 130 . the good cholesterol should be over 50 and it was 44 . so your screening for diabetes is was fine . you do have a vitamin d deficiency and i do n't know if we started the vitamin d yet or not . [patient] yes , we did . i , i do need to take one today though . [doctor] okay . so i also checked a lot of other pituitary hormones , iron levels , everything else seemed to be pretty good and in decent range . [patient] okay , that sounds great . so i wanted to also show you my liver enzymes because i have n't come back since then , but i was also happy because one of them was back to normal . [doctor] okay , great . let's see them . [patient] okay , so the one that's 30 that was almost 200 , not so long ago . [doctor] yeah , your alt was about 128 . [patient] okay and , and back in october it was 254 . [doctor] yeah , this is much better . [patient] okay , great , and then it dropped in january and then it dropped a little more in march since i stopped taking the medicine in december . [doctor] okay , that's good . so i'm proud of you with the course of your labs so before i forget , i'm gon na just put your labs into the computer today and i wo n't be checking your vitamin d level for some time . [patient] okay . so with the thyroid and the low vitamin d , does that always happen together ? [doctor] i do have a lot of people that have thyroid thyroid issues and they have vitamin d deficiency . [patient] okay . [doctor] this is what i'm , i'm going to do , i'm going to put , print out your prescriptions so you can shop around at the pharmacies and see if you can find better prices . [patient] okay , that way i can go ask them and try cvs . [doctor] yeah , that sounds like a plan . [patient] okay , good . so the weight loss study that you mentioned , when does that start or how does that work ? [doctor] so we are about to start as we just got approval last week and we are just waiting on our paperwork , so we can get started . [patient] okay and what's involved with that ? [doctor] so it'll involve you receiving a medication , which has been used for diabetes treatment , and it works mostly in the gut on satiety or satiety hormones . the most common side effects are gon na be nausea , vomiting , diarrhea , and constipation , there are six arms to the study , one is the placebo , the other ones are various , various dosages of the medication , excuse me , you would receive an injection once a week also keep in mind that most of the weight loss medications are not covered by insurance . [patient] okay . [doctor] so it's a way of getting them but the odds of getting one of the arms with the medication that are in your favor right might be only 1 out of 5 of our 100 patients that we have on the list for the study that will receive the placebo . [patient] okay . [doctor] does that make sense ? [patient] yes , it does . [doctor] so we do expect pretty big weight loss because of what we learn in the diabetes study , so it's a year long process and it's an injection once a week . you come in weekly for the first four or 5 weeks , i believe and then after that it's once a month . you do get a stype in for participating in the study and parking is validated and whatever else that you need for the study . [patient] okay , do you know how much the skypond is ? [doctor] i will have to double check for you and you do n't have to be my patient , you just have to meet the criteria so the criteria is a bmi greater than 30 if you do n't have any other medical condition or a bmi greater than 27 if you do have other medical condition like your cholesterol bmi greater than 27 would qualify you . [patient] i have a friend who might be interested and she does have diabetes . [doctor] if she has the diabetes , then she wo n't qualify . [patient] okay . you ca n't if you , if you have diabetes , got it . [doctor] correct . yeah , the only thing that they can not have really is diabetes , severe psychiatric disease or schizophrenia , bipolar , things like that . [patient] okay . [doctor] but if they have hypertension , high cholesterol , things like that , they can definitely sign up . [patient] and they can , okay , thank you for explaining that . [doctor] of course , so do you want me to try to get you into that study or would you just like to try me to prescribe you something , it's kinda up to you . [patient] i think i'll just wait for a little bit now . [doctor] alright . sounds good . i'll give you the information for the research . it's just in my office . it is a different phone number though so then if you're interested , just call us within a month because i do n't know how long the , the wait will be . [patient] okay , we will do . [doctor] perfect . so let me go grab your discount card for the unithroid . when you go in to activate it , the instructions are on this card and then you use your insurance . then show them this and ask how much it will cost . if it's too expensive , just let me know . [patient] i will , thank you so much for your help on that . [doctor] you're welcome . then what i did is i gave you a topical antibiotic plus i gave you the benzyl peroxide so the peroxide may bleach your sheets . but you want to make sure to take it and apply it at night so you do n't have a reaction from the sun during the day . [patient] okay , i can do that . [doctor] but you do also want to make sure that you do n't mess up your sheets . [patient] okay , sounds good . [doctor] so that's that and then let's see how you do on the other medications . i think this will , this will get better . in the meantime , a low carb diet , avoid alcohol and fatty foods and low cholesterol foods . [patient] okay . [doctor] and again once you finish your dose of vitamin d for the vitamin d deficiency , you're gon na start with the 2000 international units daily so that you're able to maintain those levels , sound good ? [patient] yes , that sounds great . [doctor] i really think your liver enzymes are gon na get better once you lose the weight though . [patient] okay , that would be great . [doctor] since we stopped your birth control , we can try one called fexie , which is kind of like a spermaside basically . [patient] okay . [doctor] and you just apply it before intercourse . [patient] okay . [doctor] if you need some just let me know . [patient] okay , i will , i will let you know . [doctor] okay , perfect . so stay put for me now . i'm gon na go see if they have a discount samples and bring you that prescription and then i'm going to order the labs for next time . [patient] okay , great . thank you so much . [doctor] you're welcome . so under the plan under abnormal liver enzymes , they have improved since discontinuation of her birth control . under abnormal weight gain , her dexamethasone suppression test was normal , 2 out of 3 solid chorisol tests were normal , not consistent with cushing's and therefore , ruling out cushing's . under her hirsutism , her androgen levels were normal . for the acne vulgaris , the epiduo was not covered , so we will try benzoyl peroxide with clindamycin and remove the previous information on the hypothyroidism . we will print out her prescriptions unithyroid should be better priced with the discount card and we will repeat levels of everything before next visit . thanks .

CHIEF COMPLAINT

Hypothyroidism.
Abnormal liver enzymes.
Abnormal weight gain.
Acne vulgaris.

HISTORY OF PRESENT ILLNESS

Christine Hernandez is a 39-year-old female who presents today for evaluation and management of abnormal liver enzymes and hypothyroidism.

When the patient was last seen, her thyroid medicine was changed to Unithroid, but due to the cost of $75, she has not yet started the new medicine and continues taking her previous thyroid medicine. She denies utilizing the coupon that was previously recommended for the Unithroid. Similarly, the patient was prescribed Epiduo for her acne vulgaris, which she did not fill due to the cost of $100. She tried filling both prescriptions at Walmart.

Mrs. Hernandez still presents with abnormal weight gain. She questioned if her oral contraceptive Microgestin, which was discontinued, could have been the cause. Additional symptoms included acne, hirsutism. She is attempting to modify her intake and plans to resume her gym membership in July as she will be on vacation. She inquired about the impact on weight loss of chromium, CLA, and amino acids.

The patient confirmed that she is taking her high dose Vitamin D as prescribed. She does suffer from constipation and she treats with MiraLAX.

She denies previous treatment for her acne vulgaris. She denies ever using clindamycin topical antibiotic. She reports having sensitive skin, developing rashes with various skin products.

PAST HISTORY

Medical
Hypothyroidism.
Acne Vulgaris.
Vitamin D deficiency.
Abnormal weight gain.
Hirsutism.
Constipation.

CURRENT MEDICATIONS

Benzoyl Peroxide.
Clindamycin Gel applied topically.
Vitamin D 2000 IU daily.
Unithroid.
MiraLAX.

ALLERGIES

No known allergies.

RESULTS

Dexamethasone Suppression Test: Normal.

Salivary Cortisol Tests: 2 out of 3 were normal. Not consistent with Cushing’s Syndrome.

Hepatic Function Panel: ALT 128.
Lipid Panel: Total cholesterol 222 mg/dL, HDL 44 mg/dL, LDL 153 mg/dL, non-HDL 178 mg/dL.

FAI: Normal.

ASSESSMENT

• Hypothyroidism.
• Abnormal liver enzymes.
• Abnormal weight gain.
• Acne vulgaris
• Vitamin D deficiency.
• Hirsutism

PLAN

Hypothyroidism
The patient will again attempt to initiate Unithroid. I have printed out the prescription and a discount card, which should result in a reduced price. She will contact my office if she encounters additional issues.

Abnormal liver enzymes
We have seen improvement since the discontinuation of Microgestin. I recommended the spermicide Phexxi for alternative birth control. The patient will also continue working on weight loss, which should additionally improve her liver enzymes.

Abnormal weight gain
Cushing’s Syndrome has been ruled out. I reviewed the weight loss study with the patient, she will call within a month if she is interested in participating. I advised her to follow a low carbohydrate, low cholesterol, abstain from alcohol, and reduce fatty foods diet.

Acne vulgaris
Epiduo was not covered and too expensive. The patient will try benzoyl peroxide and Clindamycin separately to see if the price improves.

Vitamin D deficiency
The patient will complete the high dose vitamin D and then should start vitamin D 2000 IU per day to maintain her levels.

Hirsutism
Her androgen levels were normal.

INSTRUCTIONS

She will repeat all labs prior to her next visit.


[patient] next patient is nicole miller , date of birth is 9/18/1949 . patient was called for a follow-up with me for chronic congestive heart failure with diastolic dysfunction . bnp has been 3000 in march and is about six , was up to 6000 in april . she was increasingly dyspneic . we changed her furosemide and torsemide 20 mg by mouth daily . to note the patient is not currently on potassium supplement , her lisinopril . has also been increased up to 10 mg daily in march also when i saw her in last april she had reported being interested in having her right knee replaced this summer at east metro so it was recommended that we work to control her cardiovascular status before surgery . [doctor] hey miss miller , how're you today ? [patient] i'm doing okay , thank you . [doctor] i asked you to come in today because we want to keep , we want you to have this knee surgery this summer but we want to keep a close eye on you to make sure a week before your surgery , you do n't suddenly go into congestive heart failure and it gets postponed . [patient] yeah , that would not be good . [doctor] i see you're scheduled on the 24th for surgery . [patient] yeah , that's right . [doctor] okay , good . well , it looks like you have lost about three , 3-1/2 pounds since i saw you last in april . some of that might be water weight , but still this is positive . [patient] yeah , i noticed that too . i think the oxybutynin is helping as well . my urgency to use the bathroom is much better . [doctor] well , that's great . [patient] yeah , i'm , i'm pleased about it too . [doctor] do you ever get leg or finger cramps or any , anything like that ? [patient] yeah , i had leg cramps the other day , but i thought it might was maybe just because i was cold as i had my ceiling fan on and fell asleep . i had cramps when i woke up in both legs right here . i drank pickle juice and it went right away . [doctor] well do n't , do n't go crazy with the pill juice because of all the salt in it . [patient] well i know , i only drink about 4 ounces or so . [doctor] okay , good . [patient] it went away , so i did n't drink anymore . i find it works a lot better than trying to put some cream on my leg . [doctor] sure , just , just keep it in moderation . [patient] okay . [doctor] and then are you still on an iron supplement and are you using the bathroom okay ? [patient] yes everything is good . [doctor] good . how is your heartburn doing ? any problems with that ? [patient] no , it did get bad for a while , so i tried to take some prilosec and then stopped that other one . [doctor] okay . [patient] i did that for like gosh , i think it was 2 weeks back in january and have n't had any problems since . [doctor] great . [patient] and after i start taking that i went back to the stomach one , so i'm doing good now . [doctor] okay and you're still due for a colonoscopy , correct ? [patient] yeah , that's right . [doctor] alright , let's , let's review your blood work real quick . i checked your hemoglobin level because you have had some anemia in the past , but that is still doing great . [patient] good , that's a relief to hear . [doctor] your potassium is 3.9 , so it's holding steady on the torsemide . your creatinine was 0.7 , 9.8 , so you're doing well with kidney numbers . your your bun . [patient] maybe a tiny bit elevated at 23 which the number we look for for dehydration , sometimes the kidneys , but it's not terrible . [doctor] so when i look at your numbers as a whole , i think you're tolerating the torsemide okay at the current dose . i also sent out to look at the heart failure number . i sent out to look at your heart failure number . [patient] there is a test called a bnp that i was monitoring and in march it was up to 3000 and then went up to 6000 in april before i made the change and i'm still waiting for those results . okay . [doctor] all in all i think you're doing good on paper though . [patient] what about what's it called a1c , does that show up ? [doctor] i do n't think i ordered it , but i could , your last a1c was 5.5 in march . [patient] already . [doctor] so your blood sugar is a little bit high , it was 169 today but that kinda depends on what you ate and you were n't fasting for the blood check , so i might have to repeat that test for preop , but i do n't think we need to do it today . [patient] alrighty , that sounds good . i checked your magnesium level because sometimes you , you urinate out magnesium and with the water pills , but it was normal at 1.7 and your , your blood pressure is also looking good . okay , great . that all sounds awesome . [doctor] alright , let's take a quick listen . use my general physical exam template and take a couple of deep breaths for me . your lungs sound pretty good to me , so keep doing what you're doing like i said , i think you're doing good overall , but let's just talk about a few things . [patient] alrighty . [doctor] so we often like to keep people with heart problems on magnesium , [patient] and get their levels up to around the two–-ish range . yours is a little bit less than two and we want that two–-ish range because because it can help stabilize the heart muscle so i might recommend putting you on a magnesium supplement . it's to be twice a day , so that's kind of annoying . but i know you're on other medicines twice a day too so i think you'll do fine . yeah that will be okay . great now before surgery , we'll have to get you off your clopidogrel for a week beforehand . yes , okay . i have everything written down on my phone and i have a letter taped the side of my bed to remind me . [doctor] perfect . we will give you a reminder as well . we will also need to complete a preop check within 2 weeks after surgery during the first or second week of june . [patient] okay . i'll put that down . you might also have to repeat an ekg before surgery which we could do today . i know i'm sure it feels like you're doing , you're always doing ekg's we do n't need to do any x-rays of your chest because you had one recently and we do n't need anymore blood work because we did that today . yeah , i do a lot of ekgs . i'm basically a regular , but i'm happy to do one today , no problem . [doctor] lastly once we get your knee surgery we , we should think about getting you a colonoscopy . we can do it here locally because you have medicare . do you have private insurance also ? [patient] yeah , i have both . [doctor] okay , so yes , you can get it , your colonoscopy , wherever you'd like . okay , well my husband's insurance may be running out , might we be able to get the procedure done sooner maybe in the next 30 days , is that okay ? [patient] i could put it in right now for for county for the next 30 days and then might be able to get you in within the next few weeks . it should not take it should not make you an eligible for the surgery . in other words , completing the colonoscopy would not delay your surgery . [doctor] okay good . [patient] so let me see , i've been doing one of two things and everyone , and everyone is great , so it depends more on timing and availability of their or for the colonoscopy we can send you to dr. martin for the surgery who is at county surgical services down here or the other option is valley medical and they do it at springfield . [doctor] okay that sounds good . [patient] i think either direction they are good technicians of the colon okay , yeah , whatever you can get me in , that works great . [doctor] so i'll call around , now if you get that done and they tell you 10 years , then you'll be good to go . [patient] great , thank you . [doctor] you're welcome . have a great day and let us know if you need anything else , okay . [patient] sounds good . alright assessment and plan , chronic chf , mixed presentation , had a exacerbation of cf chf earlier in the spring , we switched her from a furosemide to torsemide and symptomatically she is doing a lot better . she's about three , 3-1/2 pounds down in weight . breathing is nonlabored , and going to repeat ekg today , but otherwise continue her current regimen . labs checked and creatinine is appropriate . # 2 , preop examination , she is , she is having a , a right knee replacement end of june . also , she would like to have a colonoscopy performed , which we will try to have done at county hospital in the next month prior to a change in her insurance . this is just a screening colonoscopy that she is overdue for . no family history of colon cancer . the next one is . [doctor] diabetes . a1c is 5.1 on the last check , so no need for further a1c today . she may need another one prior to her surgery next month though . thanks .

CHIEF COMPLAINT

Follow-up.

HISTORY OF PRESENT ILLNESS

Nicole Miller is a 71-year-old female who presents for follow-up. The patient was called in for a follow up with me for chronic congestive heart failure with diastolic dysfunction. Her BNP had been 3000 in 03/2021, up to 6000 in 04/2021. She was increasingly dyspneic. We had changed her furosemide to torsemide at 20 mg by mouth daily. The patient is not on a potassium supplement currently. Her lisinopril had also been increased up to 10 mg daily in 03/2021.

I last saw her in 04/2021, and she had reported being interested in having her right knee replaced this summer at East Metropolitan Hospital, so it was recommended that we work to control her cardiovascular status prior to surgery. She is currently scheduled to have surgery on 06/24/2021. She plans to discontinue clopidogrel a week before her surgery.

The patient states that she has lost approximately 3 to 3.5 pounds since her last visit in 04/2021. Some of which may be water weight decreasing. She did report experiencing bilateral leg cramps which she treated with consumption of pickle juice, which did resolve the cramps. She thought the cramps were related to her being cold.

She is still taking iron supplementation. She denies any concerns with defecation.

Regarding her prior symptoms of heartburn, she denies any recent gastrointestinal issues. She notes that her heartburn was severe at one point but resolved after trying Prilosec for 2 weeks in 01/2021. She denies any issues with heartburn since that time and has stopped taking Prilosec altogether. She has since transitioned back to her original "stomach medication".

The patient is due for a colonoscopy. She is currently double covered with Medicare and private insurance.

PAST HISTORY

Medical
Chronic Congestive Heart Failure.
Iron deficiency Anemia.

Medications
Prilosec.

FAMILY HISTORY

No family history of colon cancer.

CURRENT MEDICATIONS

Torsemide 20 mg by mouth daily.
Lisinopril 10 mg daily.

RESULTS

Magnesium 1.7, hemoglobin WNL, potassium 3.9, creatinine 0.7, BUN 23.
03/2020 Hgb A1c 5.5.

ASSESSMENT

• Chronic congestive heart failure with mixed presentation.
• Preop examination.
• Diabetes mellitus.
• Colonoscopy

PLAN

Chronic congestive heart failure with mixed presentation.
She had an exacerbation of CHF earlier in the spring. We switched her from furosemide to torsemide and symptomatically, she is doing a lot better. She is about 1.5 kg down in weight. Her breathing is nonlabored. We are going to repeat an EKG today. Otherwise, continue her current regimen. Labs were checked and creatinine is appropriate. Her magnesium is below the preferred 2 at 1.7, with some occurrence of bilateral leg cramping, therefore we will start her on magnesium supplement.

Preop examination.
She is going to be having a right knee replacement at the end of 06/2021. We will schedule a preop check the first week or two of June prior to the surgery. She will discontinue clopidogrel for one week prior to knee replacement surgery; we will provide a reminder to patient of this as well.

Diabetes mellitus.
A1c is 5.5 on last check, so there is no need for a further A1c today. She may need another one prior to her surgery next month.

Colonoscopy.
The patient is overdue for a colonoscopy, which we will try to have done at County Hospital in the next month, prior to a change in her insurance. This is just a screening colonoscopy that she is overdue for. No family history of colon cancer.

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

INSTRUCTIONS

Complete EKG today. Schedule a preop checkup 1st or 2nd week of June. Start magnesium supplement. Call the clinic with any questions or new symptoms.


[doctor] patrick allen , date of birth 7/7/1977 . new patient visit . past medical history includes gerd , anxiety , depression , here for chronic abdominal pain , he had an abdominal ct on 1/23/2020 . impression is a normal ct of the abdomen . hello , are you mr. allen ? [patient] yes , i am . [doctor] hi , my name is dr. edwards , nice to meet you . [patient] nice to meet you . [doctor] welcome to the gi specialty clinic . [patient] thank you . [doctor] did you have any problems finding this ? [patient] no , i've been here with my sister once before . [doctor] good , so how can i help you today ? the referral i have is for abdominal pain and diarrhea . [patient] right so i've had been having this pain right here in my stomach like right around here . [doctor] so in the area of your mid abdomen just below the belly button ? [patient] correct . i've had the pain on and off for about 2 years . i finally went to the er and a a few months ago and they did a ct scan . [doctor] i saw that . [patient] yeah , they said they did n't really see anything on the scan . [doctor] yes , i agree , it looked normal . [patient] and the problem is i'm either constipated or have explosive diarrhea . [doctor] is the pain there all the time ? [patient] it's a nagging feeling and it just depends , sometimes it bothers me , sometimes it does n't . [doctor] has this been the case over the past 2 years as well ? [patient] more recently in the past couple of months at least with the constipation and diarrhea . [doctor] and before that , how were your bowel movements ? [patient] they were normal . [doctor] okay , so any blood in your stool ? [patient] nope . [doctor] do you feel like you have more constipation or diarrhea ? [patient] probably more constipation . [doctor] okay , so when you're constipated , do you not have a bowel movement or is the stool hard ? [patient] i usually do n't go , but when i do , it's hard . [doctor] and how often do you have a bowel movement when you are constipated ? [patient] about 3-4 times a week it's like when i need to go to the bathroom if i can massage it , it feels like it's moving some and i can eventually go . [doctor] okay and when you have a bowel movement , does the pain change ? [patient] yeah . it gets a little better . [doctor] and are you eating and drinking okay , any nausea or vomiting , heartburn or indigestion ? [patient] none of that . [doctor] okay , so tell me about the diarrhea . how often do you get it ? [patient] it kinda just depends on what i eat . i think i have a very sensitive stomach if i eat pasta with a creamy sauce i'm probably gon na have diarrhea . [doctor] okay and does it happen for multiple days in a row or is it just one time ? [patient] it's usually just one time and then it's over . [doctor] and how has your weight been , any fluctuation ? [patient] no , it's been pretty stable , although i could stand to lose about 25 pounds . [doctor] okay , and is there any family history of gi issues that you know of ? [patient] not that i can think of . well , actually my sister does have problems with her stomach too . she has irritable bowel syndrome and that is kind of what i always thought i had even though i have never been diagnosed with it . [doctor] okay and is there any family history of gi cancer or liver disease ? [patient] no . [doctor] have you ever had any surgeries on your abdomen ? [patient] i have never had any surgery . [doctor] okay , so your gallbladder , appendix , all of those are still intact ? [patient] yep . [doctor] and have you ever had a colonoscopy ? [patient] no . i thought that happened when you turned 50 . [doctor] well that's for colon cancer screening , but there are other reasons to have a colonoscopy like unexplained abdominal pain and changes in bowel habits . [patient] okay . [doctor] well , come have a seat here and lay back so i can examine you . [patient] okay . [doctor] i'm gon na start by listening to your belly with my stethoscope . [patient] okay . [doctor] and i hear bowel sounds in all four quadrants . [patient] what does that mean , is everything okay ? [doctor] it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working . [patient] okay , good . [doctor] so now i'm going to push on your upper and lower abdomen , let me know if you have any pain . [patient] it hurts a little when you push right there on the left side near my belly button . [doctor] okay , i do feel stool in your lower colon which would coincide with constipation but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ? [patient] yes . i had a physical about 4 months ago and they i had blood drawn then . [doctor] okay and did your primary care physician say anything about the lab results ? [patient] he said i had some very slightly elevated liver enzymes but we would recheck them in about 6 months . [doctor] and do you remember what enzymes were elevated , alt , ast , alp ? [patient] he said the alt and the ast were elevated . [doctor] and do you take any medications either prescription or over the counter ? [patient] i take crestor and , and olmesartan daily and then tylenol for occasional , occasional pain . [doctor] and how frequently do you take the tylenol ? [patient] hardly ever , maybe once a month . [doctor] and do you consume alcohol ? [patient] yes , but only a couple of beers after working in the yard on saturdays . [doctor] okay and no previous history of heavy alcohol or drug use ? [patient] no . [doctor] and have you had any recent issues with excessive bruising or bleeding ? [patient] nope . [doctor] and how about any issues with your ankles or feet swelling ? [patient] no . [doctor] okay , i'm gon na take a look at your eyes and skin . i do n't see any jaundice . [patient] what would cause that ? [doctor] issues with your liver . let me take a quick listen to your heart and lungs . [patient] okay . [doctor] lungs are clear bilateral . heart sounds are normal . no murmurs , gallops , or rubs noted . [patient] that's good . [doctor] yes , the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly . [patient] what's that ? [doctor] increased stool burden means that there is a lot of stool sitting in your colon . [patient] and that's the constipation , right ? but what about the other thing ? [doctor] the hepatomegaly means the liver is enlarged . [patient] but you said mom was slightly enlarged . [doctor] correct . [patient] so what does that mean ? [doctor] well , let's talk about what we found and then some possible next steps if you're in agreement . [patient] okay . [doctor] so as i said , the hepatomegaly means your liver is enlarged . [patient] could that be why my stomach is hurting and i'm having issues with the constipation and diarrhea ? [doctor] no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat and we can get you started right away on a fiber supplement that should help with that . [patient] so what about my liver , why is it enlarged ? [doctor] well , there are many reasons why people can have an elevated liver enzymes and also an enlarged liver . some possible causes are certain medications that can be toxic to the liver . alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease . [patient] so what do i need to do ? [doctor] well , i think since it's been about 4 months since your blood work was done , we should check your liver enzymes in addition to a few other labs . [patient] okay and then what ? [doctor] we will get those drawn today and then depending upon the results , you may need an ultrasound of your liver . i think we need to talk about your medications too . [patient] which medications ? [doctor] crestor , how long have you been taking that ? [patient] about 18 months . [doctor] okay , well crestor is one of the medications that can cause liver toxicity , so it may be a good idea to discuss other alternatives . [patient] should i talk to my primary care or can you change it ? [doctor] i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol . [patient] okay . i'll call him this afternoon . [doctor] great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that . [patient] okay . when do you think i'll be able to get the ultrasound done ? [doctor] hopefully within the next 2 weeks , you will receive a call from the radiology scheduling this afternoon to get it set up . [patient] okay and then what happens ? [doctor] when i get the results from the tests , i'll contact you and depending upon what we find , we'll come up with our next steps . [patient] and when should i see you again ? [doctor] let's schedule an appointment when you check out to return in 4 weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver . [patient] okay . is there anything else i can do to help with these issues ? [doctor] definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day , in addition to taking the fiber supplement to help with your constipation and be mindful of eating foods that you are sensitive to so you can avoid the bouts of diarrhea . [patient] okay and i will talk to my primary care about my crestor . [doctor] excellent and do you have any other questions for me ? [patient] i do n't think so . [doctor] great . so remember when you check out at the front desk , schedule a follow-up appointment with me for 4 weeks and then go to the lab to get your blood work drawn . [patient] okay , sounds good . [doctor] and expect a call from radiology scheduling about setting up your ultrasound . [patient] alright . thanks dr. edwards . [doctor] thank you mr. allen .

CHIEF COMPLAINT

Abdominal pain and diarrhea.

HISTORY OF PRESENT ILLNESS

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

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

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

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

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

PHYSICAL EXAM

Respiratory
Lungs clear to auscultation bilaterally.

Cardiovascular
No murmurs, gallops, or rubs.

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

RESULTS

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

ASSESSMENT

• Constipation
• Mild hepatomegaly

PLAN

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

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

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

INSTRUCTIONS

Return to clinic in 4 weeks.


[doctor] eugene walker date of birth 4/14/1960 he is a 61-year-old male who presents today for routine follow-up of his chronic medical conditions of note the patient underwent an aortic valve replacement and a sending aortic aneurysm repair on 1/22/2013 regarding his blood work from 4/10/2021 the patient's alkaline phosphatase phosphatase is me was elevated to 156 his lipid panel showed elevated total cholesterol of 247 hdl of 66 ldl of 166 and triglycerides at 74 the patient's tsh was normal at 2.68 . his cbc was unremarkable . his most recent vitamin d level was at the high end of normal at 94 . good morning mr. walker how are you doing i mean has been a crazy year i'm doing fine for the most part but there are a few things on cover today sure drawn ahead . [patient] well i'm having more fatigue , but i do n't know if it's age or if it's just you know drained at the end of the day , but i still ride my bike . i ca n't go as fast as i used to , i'm still riding and you know after a long bike ride , i'll sit down and then boom , i'm out , you know . [doctor] yeah , what's a long bike ride do you ? [patient] 20 to 30 miles . [doctor] 20 to 30 miles , on a road bike ? [patient] yeah , road bike . i think it's a time thing . if i have more time , i would try to do my 40 miles , but i have n't done that . obviously we are too early in the season , so my typical ride is like 2030 . and years back , i could do 40 on a good day . i could still do 20 , but you know i'm tired and have to take a break when i get home . [doctor] yeah , i understand . [patient] and tyler is my buddy . he is always nice and weights for me , but i used to be able to beat him , but now he waits for me all the time , he is older than me and it it kills me . [doctor] yeah , i can imagine that would help sent me to . [patient] the last time you know you found a heart thing then , just making sure that the valve is holding out , you know . [doctor] right , so when was your last stress test ? [patient] it was september 9 , 2019 because i'm 8 years out from surgery and back then they said . you know it's going to last 8 years and i'm at that year , so i just wan na make sure . i asked dr. lewis for an echocardiogram to see how i'm doing . [doctor] yeah . [patient] but it's not like nothing has changed drastically since i saw you . [doctor] okay , good . do you still go down to hopkins at all ? [patient] no , not at all . i just get follow-ups intermittently here , going there is just is too much stress . [doctor] okay . [patient] 01 more thing , i want to make sure i do n't forget . my wife and friends tell me that when i walk , i purse my lips when i'm breathing , other doctors have said did you notice your pursed lips breathing . i do n't know if that's a bad habit or what . [doctor] okay . is there any wheezing associated with that ? [patient] no , no reason . [doctor] and you're able to bike 30 miles and mostly keep up with your friend's tyler , correct ? [patient] yeah . the only other thing i wan na mention is it's not like i do routine testicular exams . but i know i have this little nodule on my right testicle . [doctor] on the testicle or the epididymis ? [patient] epididymis . i really do n't know . i'm not super concerned or read a little online , just wanted to ask you . [doctor] and did you have a vasectomy ? [patient] no . let me pull my notes out and make sure i mentioned everything i wanted to tell you . those are the only things and it's not like my tiredness is depression or anything . i'm a pretty happy guy overall , you know . i just know you would ask those questions . [doctor] what time are you going to sleep and about how many hours do you sleep at night ? [patient] it varies usually i get 6 to 7 hours of sleep , i get out of bed some days to be at work by seven lecture and i try to work out in the morning . i i do n't , i'm not , i'm not really successful and now what i do is i , i do make reservations twice a week for 545 swim in the morning . [doctor] okay , so you're getting 6 to 7 hours of sleep and has your wife ever mentioned if you snore or stop breathing at any time ? [patient] i believe i snore a little bit , but she has never said anything about me not breathing . [doctor] okay . so you're currently taking vitamin d3 around 5000 units on sundays and 2000 or 50,000 units on sundays excuse me and 2000 on the other 6 days and then clindamycin prior to dental procedures correct . [patient] yeah , that's right . [doctor] have you had a covid-19 shot yet ? [patient] i've received both . my first dose on january 15 , 2021 and my second on february 5 , 2021 . [doctor] good . if you hop up here on the table , we're just gon na do a physical exam . well mr. walker overall you're doing well i'm going to order an echocardiogram and a stress test i also recommend that you follow-up with cardiology i think dr. vincent sanchez would be a great fit for you . [patient] alright . [doctor] also your recent labs showed an elevated alkaline phosphatase level at 156 now this could be related to your liver but most likely related to your bone health we are going to check a few labs today . [patient] you're going to have them done today ? [doctor] yes sir and we will send the results through your patient portal unless something is way off and will give you a call sounds good now as far as your breathing i observe the pursed lip breathing and your exhalation is low i think you should do a pulmonary function test to further evaluate and i would evaluate as well now the nodule in your right testicle should be evaluated by urology and we will place that referral today also . [patient] sounds like you're gon na be busy getting this all checked out . [doctor] yes sir now you're due for your mmr and i'm recommending you get the shingles vaccine as well . you have completed your covid-19 so that's good . now i'm gon na have have you return in about a year for your wellness visit . we'll see you back sooner if needed after i review all those labs and those other studies . do you have any other questions for me ? [patient] no , document . i think you covered it all . [doctor] great okay the nurse will be back in a minute to give you mmr today and the front desk will line up the time to do the shingles vaccine next month thanks doc have a great day alright , use my general physical exam template . for respiratory , notate pursed lip breathing , low exhalation phase , clear to auscultation , no wheezing . genitalia notiate right testicle with 2 to 3 mm palpable nodule . does not feel as if it will does not feel as if with the epididymis or varicocele left testicle normal no hernia all other portions of the physical exam are normal default assessment history of aortic aneurysm repair the patient underwent an aortic valve replacement and a sending aortic aneurysm repair on 1/20/2013 he is doing well overall and currently asymptomatic he is currently not seen by cardiology routinely suggested following up and suggested vincent sanchez at this physician . we will perform an echocardiogram/stress test elevated alkaline phosphatase level most recent cmp showed elevation at 156 this could be related to his liver but most likely related to his bone health i have ordered an alkaline phosphatase and again a gt lung field abnormal finding on x eliciting on examination the patient has been noted to purse his lips while breathing he was found himself he has found himself feeling more fatigued at the end of the day he does bicycle around 20 to 30 miles at a time his excellent exhalation phase is low on exam and i have ordered pfts today to further for further evaluation the right testicular nodule about 2 to 3 mm noted on the exam . there is no hernia palpable and i have suggested reaching out to urology for possible ultrasound preventative health most recent blood work was reviewed with no significant abnormalities abnormalities other than the cmp we will perform nmr titer today i have suggested the shingles vaccine he is fully vaccinated against covid-19 patient will return for follow-up in 1 year for a wellness visit , sooner if needed . he is to call with any questions or concerns .

CHIEF COMPLAINT

Routine follow up of chronic medical conditions.

HISTORY OF PRESENT ILLNESS

Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions.

Today, the patient reports feeling more fatigued as of late. He notes that he usually rides his bike for about 20 to 30 miles and by the end of his ride he is tired enough that he will immediately fall asleep. The patient adds that he can fall asleep easily and gets about 6 or 7 hours of sleep per night. He believes he snores a bit but denies any signs of apnea.

Of note, the patient underwent an aortic valve replacement and ascending aortic aneurysm repair on 01/22/2013. As he is now 8 years post-op, he has requested an echocardiogram from Dr. Lewis to review how he is doing currently. His last stress test was performed on 09/09/2019.

Mr. Walker reports that his wife and friends have told him that he has pursed lips when he walks. This has also been noticed by his other providers. He denies any wheezing.

Furthermore, the patient has noticed a 2 to 3 mm nodule in his right testicle, possibly with the epididymis but he is unsure. He has not had a vasectomy.

His current medication list only consists of clindamycin prior to dental procedures and vitamin D3 (50,000 IU on Sundays and 2000 IU the other 6 days).

From a preventative standpoint, the patient is due for the shingles vaccine and an MMR titer. He is fully vaccinated for COVID-19 with his first dose on 01/15/2021 and his second dose on 02/05/2021.

PHYSICAL EXAM

Respiratory
Pursed lip breathing noted. The exhalation phase is low. Lungs are clear to auscultation, no wheezing.

Genitourinary
No hernia noted. Left testicle normal.

RESULTS

Regarding his blood work from 04/10/2021, the patient's alkaline phosphatase was elevated at 156. His lipid panel showed elevated total cholesterol of 247, HDL 66, LDL 166, and triglycerides 74. The patient's TSH was normal at 2.68. His CBC was unremarkable. His most recent vitamin D level was at the high end of normal at 94.

ASSESSMENT

• History of aortic aneurysm repair.
• Elevated alkaline phosphate level.
• Lung field abnormal finding on examination.
• Right testicular nodule.
• Preventative health.

PLAN

Mr. Eugene Walker is a 61-year-old male who presents today for a routine follow-up of his chronic medical conditions.

History of aortic aneurysm repair.
- Overall, he is doing well and currently asymptomatic.
- Currently he is not seen by cardiology routinely and I have suggested he follow up with Dr. Tyler Sanchez.
- Ordered echocardiogram and stress test.

Elevated alkaline phosphate level.
- Most recent CMP showed elevation at 156 IU/L.
- This could be related to his liver but most likely related to his bone health.
- Ordered an alkaline phosphatase and gamma GT.

Lung field abnormal finding on examination.
- The patient has been noted to purse his lips while breathing.
- He had found himself feeling more fatigued at the end of the day.
- He does cycle 20 to 30 miles at a time.
- His exhalation phase was low on exam.
- Ordered pulmonary function testing for further evaluation.

Right testicular nodule.
- 2 to 3 mm nodule noted on exam. There is no palpable hernia.
- Referral placed to urology for possible ultrasound.

Preventative health.
- Most recent blood work reviewed with no significant abnormalities.
- He is fully vaccinated against COVID-19.
- Recommend shingles vaccine next month.
- MMR titer performed today.

INSTRUCTIONS

- Return in 1 year for routine wellness visit, sooner if needed.
- Call with any questions or concerns.