[doctor] donna torres , date of birth 8/1/1980 . hi donna , how are you ? [patient] i'm good , how about you ? [doctor] i'm doing well , thank you and so i saw that doctor brown put you on buspar . have you been on that before ? [patient] no , that's new . [doctor] okay . how is it working for you ? [patient] my anxiety's going good now . thankfully , i'm serious . it was brutal in november and december . finally , i was like i can not do this . i have no idea why it happened . dr. ward did put me on singulair , she did say we need to be careful because singulair can cause anxiety , so i'm not sure if that was the issue or what . [doctor] hmmm okay . [patient] and i would start usually during the day at work . [doctor] i see . [patient] i mean i'm fine now . [doctor] well , that's good that things have settled . i do wonder if some of what you were dealing with is hormonal and that's why i was asking because you were on the progesterone and i feel like you were having some irritability back then too . [patient] i did . [doctor] and that was before we started the progesterone . [patient] yes . [doctor] so i know we started for regulating your periods , but perhaps it helped with this also . [patient] yeah , and before in november and december , i noticed that the week before my period , my anxiety would go through the roof , which then i knew my period was coming , then it turned into my anxiety spiking , just at random times . [doctor] hmmm okay . [patient] and it seemed like it was for no reason . [doctor] but november and december you were on the progesterone at that time . [patient] yes . [doctor] alright , so not really a link there , alright . [patient] yeah , i do n't know . [doctor] yeah , i do n't know either . sometimes with the aging process , that can happen too . [patient] i figured maybe that's what it was . [doctor] and we did go through the go live in november and december so that can be pretty stressful also . [patient] yeah and that worked and that's when i first started to leave the process of delivering the results to patients with covid in the beginning of the whole pandemic , patients would have to wait 9 days before they get their results and then we open the evaluation centers and the covid clinic , so i think it just took a toll on me . [doctor] yeah , i can absolutely see that . [patient] yeah and then i was feeling selfish because i was n't even on the front lines i mean i was supporting people sure but i was n't in the icu so i felt selfish and guilty i mean hands down , the physicians and nurses were in the thick of it and there i was having anxiety and it's not ridiculous . [doctor] well , honestly you feel how you feel and what you were doing was n't easy as well , so but let's see , i need to just put this dax back to work . alright . so no other issues whatsoever ? [patient] no . [doctor] have you lost weight ? [patient] no , when i stopped taking the camilla birth control , my hunger level was at a new high . i mean i was eating constantly . i felt like what was going on . [doctor] alright . [patient] and now i am feeling better . [doctor] okay . that's good . and your mask face though , it does look thinner . [patient] well , in the past 6 months , i have lost some weight . [doctor] okay , good . anything else going on ? [patient] no . [doctor] alright . so your pap was in 2019 . i do n't think that we need to repeat that because it was negative , negative . have you ever had an abnormal pap ? [patient] not with you , but i did around 2009 and then i had to be seen every 6 months for a while and then i had a normal pap . [doctor] alright , well let's just repeat it then . [patient] yeah , that's fine with me to be safe . [doctor] okay . i know it sounds superstitious , but i feel like with all the immunocompromising , the pressure , the stress that people's bodies have been under and the potential for getting covid , or the vaccine , i have actually seen some an increase in abnormal paps in people who have been fine for a while , so that's why i figure let's just check . [patient] okay . and i fight the vaccine fight every day at home because my husband is n't ready to get it , same with my daughter . she shares the same worries as her dad and how will it impact her when she gets older . [doctor] have you had the vaccine ? [patient] yes , i have and so has my son , he has had his first already . [doctor] okay , well , you know you can only do what you can do . [patient] yeah , i agree . [doctor] alright , well , let's complete your exam . [patient] alright . [doctor] so let's take a deep breath , and again alright you can breathe normally . [patient] alright and take one more deep breath , [doctor] okay , now i'm gon na touch your neck . go ahead and swallow . perfect and just place your hand above your head okay , i do feel some little bumps . [patient] yeah , but they are not as big as they were . [doctor] mm-hmm . okay , in this breast , it does feel a little bit denseer . does it hurt at all ? [patient] it does where your left hand just was . [doctor] okay , right here ? [patient] yeah , down here , but whenever i breast-fed , it was always sore there too , i had a clog and something else , the lumps do feel smaller , but they are still there unfortunately . [doctor] yeah , they are , well now i do n't know because if it was the progesterone , they would have gone away . [patient] yeah . [doctor] alright , well just let your knees just relax and open . how's the itching or discomfort ? are you still using the cream ? [patient] yes and i actually need to get that refilled for the first time ever . [doctor] okay . [patient] but yeah , i use it once a week and it does help . [doctor] okay , great . alright , looks good . [patient] good . [doctor] you can go ahead and sit up . [patient] thank you . [doctor] alright , so typically the lumps would often just shrink up pretty quickly after you've had one or two cycles and you've had two cycles so far . so i think let's just keep monitoring them for now . [patient] okay . and what could that mean ? [doctor] well , so just like people have an increased risk of breast cancer , there is also an increased risk for breast issues . you know what i mean ? so for example , cyst . and lumps and fibroadenomas . those are all benign things . they are annoying and requires some work-up , but they are all benign . [patient] and i'm , i'm just worried because i'm almost full . 40 and my mom was almost 45 when she was diagnosed with breast cancer , so i mean i know there is nothing i can do about it but it's just i feel like we had it under control and now it is n't . [doctor] well i would n't say that . i mean i feel like we're at a point where we have a good cadence for you having surveillance on things and i think you are more aware of your breasts than ever before and things actually have n't changed . [patient] yeah . [doctor] so those are all good things . [patient] okay . [doctor] because if it was cancer , it would actually we would see some change . [patient] it would , okay . thank you for explaining that . [doctor] yeah . so i know it's annoying and distressing . but i think that's where we're at . it's annoying that you have the breast issue and it's annoying that we have to follow them . [patient] yeah , i agree there . [doctor] but the only extra that i could potentially do is we could get a breast specialist on the team and have you start to follow with them and one of the advantages there is that they sometimes will do an ultrasound as an extension of their physical exam in the office to check out , check it out on their own . they also have a lot more experience and more willingness to sometimes perform procedures earlier if they think it needs if they think it needs to be done . and i think they tend to be much quicker than you know like radiology is to biopsy it . [patient] okay . i'll do whatever you think i should . [doctor] alright . well , i think since you're feeling worried , let's go ahead and we can get them on board . i'll send out a referral and they will call you within the next couple of business days to schedule . [patient] okay , i think that sounds great . [doctor] alright , i do too . alright , well any questions or anything else we can discuss today ? [patient] no , i think i'm all set . [doctor] alright , good . alright , well have a good rest of your day and just give us a call if you need anything else . [patient] alright , thank you . you have a good day too . [doctor] alright .

CHIEF COMPLAINT

Follow-up bilateral breast cysts.

HISTORY OF PRESENT ILLNESS

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

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

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

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

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

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

PAST HISTORY

Medical
Bilateral breast cysts.
Anxiety.

SOCIAL HISTORY

Employed in healthcare, supports Covid evaluation centers and clinics.

FAMILY HISTORY

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

CURRENT MEDICATIONS

Buspar.
Singulair.

PHYSICAL EXAM

Genitourinary
Breast: Breast density.

ASSESSMENT

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

PLAN

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

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

INSTRUCTIONS

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


[doctor] sophia brown , date of birth 3/17/1946 . this is a new patient visit . she is here to establish care for history of dcis . we'll go over the history with the patient . hello miss brown . [patient] hi , yes , that's me . [doctor] wonderful . i'm dr. stewart , it's lovely to meet you . you as well . so you've come to see me today because you had a right breast lumpectomy last year , is that right ? [patient] yes on january 20 , 2020 . [doctor] okay and how you've been since then ? any problems or concerns ? no , i'm feeling good . i do my self breast exams religiously now and have n't felt anything since . perfect . i want to back up and go over your history , so i can make sure everything in your chart is correct and i do n't miss anything . so i will tell you what we have in your chart from your other providers and you tell me if anything is wrong or missing , sound good ? [patient] sounds good . [doctor] great so i have that you were found to have a calcification in your right breast during a mammogram in october 2019 . was that just a normal screening mammogram or was it done because you felt a lump ? it was just a normal one , you were supposed to get every so often . i see and then it looks like you had an ultrasound of your right breast on november 3 , 2019 which revealed a mass at the 2 o'clock position 11 cm from the nipple in the retroareolar region . the report states the mass was . [patient] 0.4 x 2 x 3 cm . [doctor] yes , that sounds right , hard to remember now though . [patient] yeah , definitely . [doctor] based on those results , they decided to do an ultrasound-guided core needle biopsy on december 5 , 2019 . pathology results during that biopsy came back as grade 2 , er positive , pr positive dcis , [patient] or ductal carcinoma in situ . [doctor] yes unfortunately . i know scary stuff but you had a lumpectomy on january 20 , 2020 which removed the 8 mm tumor and margins were negative . [patient] the pathology confirmed dcis looks like they also removed five lymph nodes , which thankfully were negative for malignancy . that's great . [doctor] yeah , i was definitely very relieved . and your last mammogram was in january 2021 and that was normal . [patient] yeah . [doctor] okay . so i feel like i have a good grasp of what's been going on with you now and you're here today to establish . [patient] care with me so i can continue to follow you and make sure you're doing well , right ? [doctor] yes , fingers crossed . [patient] definitely . we'll keep a close eye on you and take good care of you . [doctor] okay , sounds good . i have a few more questions for you . when was your last colonoscopy ? i had one in 2018 and if i remember correctly , i had one polyp and that was removed and it was n't cancerous . [patient] okay , yes , i see that report now . one polyp in the sigmoid colon which had a benign tubular angioma okay and when was your last menstrual period ? [doctor] gosh , it was probably around 30 years ago . [patient] okay . do you have children ? [doctor] i do , i have five . [patient] big family then , that's nice . [doctor] yes and they are all having kids in their own now , so it's getting even bigger . [patient] i bet , sounds like fun . [doctor] it is . did you have any other pregnancies that were miscarriages or terminations ? [patient] believe i did not . [doctor] okay , so for the record that's g5 , p5 . and now that you're postmenopausal , are you currently or have you ever been on hormone replacement therapy ? [patient] my primary care doctor gave me the option years ago , but i decided against it . [doctor] okay . and on your review of systems form , you indicated that you've not had any recent weight loss , or gain , headaches , bone pain , urinary symptoms , or blood in the stools , but you did indicate that you have some back pain , joint pain , and high cholesterol . tell me some more about those . okay . so i've seen doctors for all of those . they said excuse me , the back and knee pain are age related and the cholesterol is a fairly new diagnosis . but i am working on exercise and cutting back on fatty foods to see if i can get it lower without any medication . okay and your primary care doctor is following you for that right ? [patient] that's correct . [doctor] okay . for medications , i have that you take coq10 , vitamin d , vitamin c , fish oil , and elderberry fruit , is that alright ? [patient] yes and that's all . [doctor] okay . so for your medical history , it's high cholesterol and stage 0 , er , pr positive , invasive ductal carcinoma of the right breast . any surgeries other than the lumpectomy ? [patient] i did have my tubes tied after my last baby , but that's all . [doctor] okay and how about family history ? [patient] my mom had non-hodgkin's lymphoma and my dad had prostate cancer and heart disease , but i think that's it . [doctor] alright . any family history of breast cancer ? [patient] none . [doctor] did any of your children have medical issues or siblings with medical problems ? i do not have any siblings and thankfully my children are all healthy . wonderful . do you have any history of smoking , illicit drug use , heavy alcohol consumption ? [patient] no drugs , i do drink socially but never more than that . [doctor] and i used to smoke but really everybody did back then and i probably quit about 30 years ago . [patient] excellent . i have that you're allergic to penicillin . any other allergies ? [doctor] no , just penicillin . okay , i think that covers it . hop up here and let me take a look at you . okay , so let's use the normal new patient exam template . only change to make is the breast exam . there are no palpable masses , however , there is skin thickening at the medial inferior aspect of the right breast , which may be radiation , skin changes . [patient] in the result section note that her ecog performance status today is zero . do you have , did you have radiation after the lumpectomy ? [doctor] i did . we also talked about endocrine therapy , but i decided against that . okay . so your exam looks good . no masses , just some skin changes from that radiation . now let's go over the plan for you . [patient] okay , sounds good . [doctor] as you know you had dcis which will list in my note is stage 0 er/pr positive invasive ductal carcinoma of the right breast . you're status post lumpectomy with removal of five lymph nodes that were benign . you also had radiation therapy , but declined endocrine therapy . today's clinical examination shows no evidence of recurrence with the dcis or other malignancy . [patient] and your mammogram in january 2021 was also negative for recurrence of malignancy . so based on all of that , we can just continue to observe you . [doctor] okay , that sounds great and when do i come back in to see you ? in a year , but you should have another mammogram in april 2022 before you come back to see me . [patient] okay . i can do that . [doctor] wonderful . i'm glad to see you doing so well . do you have any questions or concerns i can address for you today ? [patient] i do n't think so . [doctor] okay , great . my nurse will be in shortly to discharge you . take care . you as well .

CHIEF COMPLAINT

History of right ductal carcinoma in situ (DCIS).

HISTORY OF PRESENT ILLNESS

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

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

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

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

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

PAST HISTORY

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

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

SOCIAL HISTORY

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

FAMILY HISTORY

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

CURRENT MEDICATIONS

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

ALLERGIES

Penicillin.

REVIEW OF SYSTEMS

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

PHYSICAL EXAM

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

ASSESSMENT

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

PLAN

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


[doctor] next patient is sophia jackson , mrnr 472348 . she is a 57-year-old female who is here for a surgical consult . [patient] her dermatologist referred her . she biopsied a 0.7 mm lesion which was located on the right inferior back . pathology came back as melanoma . [doctor] mrs. jackson , it's good to meet you . [patient] likewise , wish you were under better circumstances . [doctor] yeah , i heard your dermatologist sent you to because she found the melanoma . [patient] yes , that's what the biopsy said . [doctor] okay and when did you first notice the spot ? [patient] my mom noticed it when i was visiting her last month . [doctor] i see and so you went to the dermatologist on april 10 to get it checked out , right ? [patient] yes , i wanted to be extra cautious because skin cancer does run in my family . [doctor] well i'm really glad you took a serious and got it checked . who in your family has had skin cancer and do you know if it was melanoma or was it basal cell or squamous cell ? [patient] my mom and her sister i think they both had melanoma . [doctor] okay . do you have any other types of cancer in the family like breast or ovarian ? [patient] my grandfather had pancreatic cancer . [doctor] okay and what about your mom or dad's father ? [patient] mother's . [doctor] okay and have you personally had any skin spots in the past that you got checked out and they were cancerous or precancerous ? [patient] no , this was the first time i've been to a dermatologist but my primary care doctor looks over all of my moles every year . my physical and has n't said he is concerned about any of them before . [doctor] good , good . let's go over your medical history here in your chart . i have that you are not taking any medications and do n't have any health problems listed , but that you are allergic to augmentin , is that right ? [patient] yes , that's correct . [doctor] okay and for social history , can you tell me what you do for work ? [patient] i own an auto repair shop . okay and have you ever been a smoker ? yeah , i still smoke from time to time . i started that awful habit in my teens and it's hard to break , but i'm trying . [doctor] i'm glad you're trying to quit . what about your surgical history ? have you had any surgeries ? [patient] i had gallbladder and appendix . [doctor] okay , great . we can get your chart up to date now , thank you . and other than the melanoma , how has your health been ? any unintentional weight changes , headaches , fatigue , nausea , vomiting , vision changes ? [patient] no , i've been feeling great . [doctor] good . well , let me take a look at your back here where they did the biopsy if you do n't mind . [patient] sure . [doctor] okay . i'm gon na describe it in medical jargon , what i'm seeing here so that the recording can capture it , but you and i are gon na go over it together in just a moment , okay ? [patient] okay , that's fine . [doctor] alright , so on the right inferior back , there is a 1 cm shave biopsy site including all of the dermis with no residual pigmentation there is no intrinsic or satellite lesions . no other suspicious moles . no axillary , cervical or supraclavicular lymphadenopathy . there is a soft lymph node in the right groin but it's nontender . otherwise normal exam . [patient] okay , you can sit up . so what i was saying there is that i see your biopsy site , but i do n't see any other skin lumps or bumps that look suspicious . [doctor] i also felt your lymph nodes to see if any of them felt abnormal . there is one in the right groin that felt slightly abnormal . it's very likely nothing , but i do want you to have an ultrasound of that area to confirm it's nothing . and you know make sure it's something we need to worry about the reason we are being extra cautious is that melanoma can very rarely metastasize to the lymph nodes . the ultrasound can tell us if we need to look into this further . [patient] okay . i should have worried too much then . [doctor] no , i have a low suspicion that it will show anything . [patient] okay , good . [doctor] so assuming that the ultrasound is normal . the treatment for your melanoma is to cut out the area where the lesion was . with lesions that are 0.7 mm or less and that's what we recommend and yours was exactly 0.7 mm . if it were any bigger , we would have had to do a more complex surgery , but what i recommend for you is what we call a wide local incision , excuse me , excision meaning that i will make a long incision and then cut out an area a bit wider than your current biopsy site . the incision is long because that's what allows me to close the skin nicely . you'll have a fairly long scar from the incision . [patient] okay , that is fine with me . i ca n't see back there anyways . [doctor] yeah , your wife can tell you what it looks like and she may need to help care for the incision at it as it heals . but since we're we are n't doing the more complex surgery , i actually do n't need to see you back unless you wan na check in with me or have any problems , however , it is very important that you continue to follow up with your dermatologist regularly , so she can monitor you . your dermatologist will check if this one does n't come back , but she will also check for other lesions that look suspicious . unfortunately since you had one melanoma , you are at a higher risk of developing another one somewhere else . [patient] yeah , she did say she wants to see me back . [doctor] good and i'm sure she has already told you , but it's very important that you apply sunscreen anytime and anywhere that your skin is exposed to sunlight . [patient] yeah , she definitely went over that several times with me . [doctor] good . other than that , i think that's all for me . we'll get you set up for the ultrasound and the procedure . do you have any questions for me ? [patient] no , i ca n't think of any at this time . [doctor] okay . my nurse will be in to get you scheduled . so sit tight . it was very good to meet you . [patient] thank you . nice to meet you as well . [doctor] please add the following pathology to results a pathology , shave of right inferior back , malignant melanoma , invasive superficial spreading , histology , superficial spreading . clark level iv , breslow thickness 0.7 mm , radial growth phase present , vertical growth phase not identified , mitotic features less than 1 mm² , ulceration not identified , regression not identified , [patient] lymphatic invasion not identified . perineural invasion not identified , microscopic satellitosis not identified , infiltrating lymphocytes , breast , [doctor] melanocytic nevus not identified , predominant cytology , epithelioid , peripheral margin positive , deep margin negative , stage i . also note that i reviewed the dermatologist photo of the lesion , which showed an asymmetric black and brown nevus with central asmelanotic component and a regular border . for assessment and plan , the patient presents today with newly diagnosed melanoma . biopsy revealed an intermediate thickness melanoma . on examination today , there is right inguinal lymph node with slightly atypical consistency . [patient] i recommended an ultrasound to rule out metastatic disease . if the ultrasound is normal , the patient is a candidate for wide local excision with a 1 to 2 cm margin . primary closure should be possible , but skin graft closure may be needed . the relationship between tumor histology and prognosis and treatment was carefully reviewed . the need for follow-up according to the national comprehensive cancer network guidelines was reviewed . we also reviewed the principles of sun avoidance , skin self-examination and the abcde's of mole surveillance . after discussing the procedure , risk and expected outcomes and possible complications , questions were answered and the patient expressed understanding and did choose to proceed .

CHIEF COMPLAINT

Melanoma.

HISTORY OF PRESENT ILLNESS

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

PAST HISTORY

Medical
None reported.

Surgical
Cholecystectomy.
Appendectomy.

SOCIAL HISTORY

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

FAMILY HISTORY

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

MEDICATIONS

None.

ALLERGIES

Augmentin.

PHYSICAL EXAM

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

RESULTS

Pathology Report.

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

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

ASSESSMENT AND PLAN

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


[doctor] this is philip gutierrez date of birth 1/12/1971 . he is a 50-year-old male here for a second opinion regarding the index finger on the right hand . [patient] he had a hyperextension injury of that index finger during a motor vehicle accident in march of this year . he was offered an injection of the a1 pulley region , but did not want any steroid because of the reaction to dexamethasone , which causes his heart to race . [doctor] he was scheduled to see dr. alice davis , which it does n't appear he did . he had an mri of that finger because there was concern about a capsular strain plus or minus rupture of fds tendon end . [patient] he has been seen at point may orthopedics largely by the physical therapy staff and a pr pa at that institution . at that practice , an mri was obtained on 4/24/2021 . [doctor] which showed just focal soft tissue swelling over the right index mcp joint partial thickness tear of the right fds and fluid consistent with tenosynovitis around the fdp and fds tendons . radial and ulnar collateral ligaments of the index mcp joint were intact as the mcp joint capsule . extensor tendons also deemed intact . his x-rays four views of the right hand today show no bony abnormalities , joint congruency throughout all lesser digits on the right hand . no soft tissue shadows of concern . no arthritis . hi , how are you mr . gutierrez ? i'm good how about you ? [patient] well how can i help you today ? so i was a passenger in a car that was rear-ended and we were hit multiple times i felt two bumps which slugged me forward and caused me to stretch out my right index finger . [doctor] so hitting the car in front of you all made that finger go backwards ? [patient] i do n't really know , i just felt like it felt like i laid on my finger and so i felt like it went back and it's been hurting since about march and it's been like that ever , ever since the wreck happened , so i and i ca n't make a fist but sometimes the pain is unbearable and like even driving hurts . [doctor] okay . so this was march of this year , so maybe about 3 months ago ? [patient] yeah . and it's still swollen . so i was seeing an orthopedist and they sent me to an occupational therapist and i've been doing therapy with them and then they sent me to go back and get an mri , so i went and got the mri then they told me that the mri came back . and i said i had a tear in my finger , but he was n't gon na give me an injection because the injection was going to make the tear worse . [doctor] mm-hmm . [patient] and then after he got the mri he said that i have a tear in my finger and that he did n't want to do surgery , but he would do an injection . then i'm thinking that you told me you would n't do an injection in there and then the occupational therapy says it's because of the tear , and then they do n't want me to keep rubbing the thing and doing things with my hand , so i feel like i'm not getting medical care really . [doctor] hmmm yeah , i see that . [patient] so i came to see if you could do anything for this hand because i am right handed and i kinda need that hand . [doctor] mm-hmm what do you do for a living ? [patient] i'm an x-ray tech . [doctor] wow so do you have any diabetes or rheumatoid arthritis ? [patient] nope . do you take any chronic medications of significance ? [doctor] i do take a blood pressure pill and that's it . [patient] okay and it looks like you suffer from itching with the methyl prednisone ? [doctor] that's correct . alright , well , i'm gon na scoot up closer and just take a quick look at your hand . alright , so lean over here . alright , so on this exam today , we have a very pleasant , cooperative , healthy male , no distress . his heart rate is regular rate , rhythm , 2+ radial pulse . no swelling or bruise , bruising in the palm over the volar surface of his index finger . normal creases , slightly diminished over the tip of the index finger compared to the middle finger . [patient] his index finger rest in a 10 degree pip flexed position alright , is that uncomfortable to correct that and is it uncomfortable now here ? [doctor] yeah when you push on it , yeah . [patient] alright , how about here ? there it's not . [doctor] okay , not as bad . [patient] yeah , it feels little numb . [doctor] gotcha , alright , bend , bend the tip of this finger , bend it as hard as you can , keep bending , keep bending , alright , straighten it out , [patient] alright , and now bend it for me as best you can . my goodness , feels like it's it's tearing in there . okay , okay . well , bend the tip of this finger and bend it as hard as you can , keep bending , alright , straighten that out and now bend it for me as best as you can , [doctor] alright , good . now bend that finger and i'm going to pull , put it down like this and then bend that finger for me , okay , sorry , can you bend it for me ? alright , now make a fist , great , so relax the finger , alright , so just keep it , keep when i bend the finger , we're just going to bend that finger where it meets the hand , is that okay there ? [patient] ow , ah . [doctor] okay , okay , so all the hurt it seems is stretching because you have n't been doing this for so long , so you know what i mean so you're going to have to start really doing that . [patient] well , i've tried , i even bought myself a splint . [doctor] well , but a splint does n't help move you , it actually immobilizes you . [patient] okay , i thought it would straighten it out . [doctor] no , no , so , so you really need to start bending the finger right here for me as hard as you can and keep going , going , alright , so , so you're okay . alright , so i would say the following that there is a partial tear in one of the two flexor tendons . there is the fdp and the fds and the fds is the least important of the two . so the mri shows that it's the fds the flexor digitorum , superficialis which is the least important of the two . [patient] okay . [doctor] now there are two halves of it , so it's the partial tear of one half of a whole tendon . that's not that important and the other one is just fine . so the good one is good ? [patient] yes , correct . so the one that goes all the way to the tip is good . [doctor] okay , good . [patient] yeah , so you know i think what you have got so much scar tissue and inflammation around the fds tendon , [doctor] blocking excursion of these other tendons that they ca n't get through to the pulley . [patient] okay . alright . [doctor] so what i would recommend what we try is a cortisone injection and i would avoid the dexamethasone because i saw you have a little reaction to that . but we could use the betamethasone which is a sellastone i've gotten another methylprednisolone and that itching like crazy . [patient] did it , yeah , this one is water soluble and i think it's fairly low toxicity , but high benefit and i think decreasing the pain will encourage you to move that finger . [doctor] alright , we'll give it a try . good . so you do the shot and it's going to take about 3 to 5 days before it starts feeling better and then probably over the next couple of weeks , it'll start feeling even better . [patient] perfect . [doctor] alright , so take advantage of that . you got ta start moving the finger . you're not gon na tear anything or break a bone because your intensors , extensors are intact . but your collateral ligaments are intact , so you got a sore finger . i'm going to try to help as much as i can with this soreness part and then you have to do all the stiff part . [patient] the lady in occupational therapy tried some maneuvers to straighten the finger out , but it even hurt after i left . the whole thing just swelled up . [doctor] hmmm okay . so it was injured and you had scar tissue and then you had posttraumatic inflammation and so this will help some with all of that . it's not going to make it to where your finger is like my finger does n't hurt at all , but it will make it to where at least tolerable to where you can make some gains and we actually might need to repeat this as well . [patient] well i'll be able to drive , i drove myself here today so . [doctor] yeah , it may feel a little weird , but it's totally safe for you to drive . okay , good . [patient] so for mr . gutierrez , just put that he has a posttraumatic rather severe stenosing tenosynovitis of his right index finger . [doctor] and the plan is steroid injection today , do a trigger injection , but i'm using a cc of betamethasone . so mr . gutierrez , do you have therapy scheduled or set up ? [patient] not at the moment . [doctor] alright , well , i mean you know that you need to move that finger and i think to the degree that they can help you do that . so , i want you to move that finger finger , but i think it would be beneficial for you to have an accountability . [patient] so at least you know to check in with them once a week with somebody . [doctor] okay that's kinda why i'm here for you , tell me what needs to be done , you know . [patient] yeah , so i'll write you out , [doctor] an outpatient prescription . i think if you go back to the same people where you were before , i'm hoping that after this injection , you're going to be able to do a whole lot more with them . so let's do outpatient , once a week for 6 weeks , [patient] and then full active and passive range of motion is the goal with no restrictions . [doctor] alright sounds like a plan . [patient] alright , well i will have the nurse set up the injection procedure and we'll and i'll be back shortly . [doctor] thanks document . right trigger finger injection template , attempted to inject 1 cc of celestone with half a cc of lidocaine however , the patient had a dramatic and violent , painful reaction to the introduction of the needle with contortions of the hand and with dangerously withdrawing the hand with concerns for secondary needle stick . needle was withdrawn . the patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath . we attempted a second time for a similar injection using the same technique with 1 cc of celestone and half a cc of lidocaine . [patient] a small palmar vein bled a scant amount , which was cleaned up and band-aid applied . reassured on multiple occasions that no harm was done to his finger . recommended icing and it this evening and taking ibuprofen .

CHIEF COMPLAINT

Right index finger hyperextension injury.

HISTORY OF PRESENT ILLNESS

Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion regarding evaluation of the right index finger hyperextension injury sustained during a motor vehicle accident in 03/2021.

In summary, the patient was the passenger in a vehicle that was rear-ended. He reports they were hit multiple times as he felt 2 bumps which caused his to sling forward hyperextending his right index finger. He was offered an injection of the A1 pulley region, but he did not want any steroid due to a reaction to dexamethasone that causes his heart to race. The patient was scheduled to see Dr. Alice Davis, but he has not seen his yet. The patient has been seen at Point May Orthopedics, by the physical therapy staff and a physician assistant at that practice. He underwent an MRI of the right index finger because they were concerned about a capsular strain plus or minus a rupture of the "FDS tendon."

The patient states that he is unable to make a fist secondary to pain and swelling in the right index finger. He describes a pulling, tearing sensation in the right index finger. The pain is exacerbated by driving. He notes that he has been wearing a right index finger splint.

The patient denies any history of diabetes or rheumatoid arthritis. He reports only taking medication for hypertension and denies taking any other chronic medications of significance. He also notes methylprednisolone causes his to itch.

Ms. Gutierrez is employed as an x-ray technician.

PAST HISTORY

Medical
Hypertension.

SOCIAL HISTORY

Employed as x-ray technician.

ALLERGIES

Methylprednisolone causes itching.
Dexamethasone causes palpitations.

REVIEW OF SYSTEMS

• Musculoskeletal: Right index finger pain.
• Endocrine: Denies diabetes.

PHYSICAL EXAM

Constitutional
Very pleasant, healthy appearing, cooperative male in no distress.

Neurological
Grossly intact. Slightly diminished sensation to light touch over the right PIP joint of the index finger compared to the middle finger.

Cardiovascular
Regular rate and rhythm.

Musculoskeletal
Exam of the right hand, there is no swelling or ecchymosis in the palm on the volar surface of his index finger. Normal creases are noted. Index finger rests in a 10 degree PIP joint flexed position with discomfort upon correction. Bilateral extremities 2+ radial pulses.

RESULTS

X-rays today, 4 views of the right hand, show no bony abnormalities. Joint congruency throughout all lesser digits on the right hand. No soft tissue shadows of concern. No arthritis.

MRI of the right index finger performed on 04/24/2021. Independent review of the images shows focal soft tissue swelling over the right index MCP joint, partial-thickness tear of the right FDS, and fluid consistent with tenosynovitis around the FDP and FDS tendons. Radial and ulnar collateral ligaments of the index MCP joint were intact as was the MCP joint capsule. The extensor tendons were also deemed intact.

ASSESSMENT

• Stenosing tenosynovitis of right index finger.

Ms. Philip Gutierrez is a pleasant 50-year-old right-hand-dominant male here today for a 2nd opinion of his right index finger hyperextension injury sustained during a motor vehicle accident in March of this year. The findings of his examination are consistent with rather severe post-traumatic stenosing tenosynovitis.

PLAN

The patient and I had a lengthy discussion regarding his history, symptoms, and radiographic findings. We discussed the pathophysiology and natural history of stenosing tenosynovitis and the anatomy of the flexor tendons and pulley system in the hand. I explained to the patient that the flexor digitorum superficialis tendon was clearly intact and that He is suffering from post-traumatic inflammation around the flexor digitorum superficialis tendon blocking excursion of the flexor tendons to the A1 pulley.

Treatment options were discussed including conservative management with corticosteroid injections and their statistical effectiveness. Surgical correction was also briefly discussed, although I recommend exhausting non-operative measures with a minimum of 2 injections before proceeding with surgery. I recommended a right index trigger finger cortisone injection today, and the patient elected to proceed. I also recommend that the patient report to occupational therapy once a week for the next 6 weeks to work on full active and passive right index finger range of motion with no restrictions.

The patient verbalizes understanding with the treatment plan and agrees. All questions were answered to the patient's satisfaction today.

PROCEDURE

Right index trigger finger injection.
The patient understands the risks and benefits and elected to proceed, signed consent obtained. An attempt was made to inject 1.0 cc of Celestone with 0.5 cc of lidocaine. However, the patient had a dramatic and violent painful reaction to the introduction of the needle with contortions of the hand and with dangerously withdrawing the hand with concerns for secondary needle stick. Therefore, the needle was withdrawn. The patient was counseled as to the importance of attempting to get some therapeutic steroid in the flexor tendon sheath. We attempted a 2nd time for a similar injection using the same technique with 1.0 cc of Celestone and 0.5 cc of lidocaine. There was a small palmar vein that bled a scant amount, which was cleaned up off the back of the patient's hand. A Band-Aid was applied. He was reassured on multiple occasions that no harm was done to his finger. I recommended icing it this evening and taking ibuprofen.

INSTRUCTIONS

Occupational therapy as prescribed.


[patient] good morning miss reyes . [doctor] good morning . [patient] how are you doing ma'am ? [doctor] i'm doing well dr. , how are you ? [patient] i am fine , thank you . so you've been having some problems with your right hip ? [doctor] yeah . [patient] okay and where are you hurting ? can you show me ? [doctor] right in the groin area . [patient] okay and this has been going on since february 2020 ? [doctor] yeah . [patient] okay and is it worse with movement ? [doctor] and i almost fall back okay so kind of grabs you yet okay this all started when you were walking while walking around the infusion room okay so it started if i took a step back or you know sep like that now it happens anywhere . [patient] okay , so now it hurts whenever you move . [doctor] it hurts when i pivot . [patient] okay , so if you pivot , then it hurts , got it . [doctor] sometimes do it sometimes it will go and sometimes it will do it several times in a row several times in a row okay and sometimes i fall . [patient] okay and you rate the pain to range from 2-7 out of 10 ? yeah , that's correct . okay and are you experiencing fever or chills ? no . okay and any tingling or numbness ? no . [doctor] and have you had any problems with your bowel or bladder ? [patient] no . [doctor] okay and if you stay still , do you feel better ? yes , but i do n't want to stay still . [patient] i understand , no problem and for past medical history , do you have anything going on ? [doctor] pcos i had infertility gallbladder removed but that that okay and for family history it looks like there is high blood pressure diabetes . [patient] thyroid disease , heart disease , kidney disease , and gastric ulcers for your current medications , it does n't look like you're taking anything at this time and you are allergic to percocet , vicodin and reglan and it looks like you had intentional weight loss , [doctor] yes i've lost 110 pounds . [patient] that is awesome and how did you do that with weight watchers great and how many months have you been participating in weight watchers ? [doctor] i started in 2018 and i've been at my current weight for a little over a year . [patient] that is awesome . [doctor] yeah , thank you . [patient] yeah very good and congratulations and so for social history , it looks like you work at an infusion center . [doctor] yes . [patient] okay and you live with your roommate , no history of tobacco and alcohol intake less than five drinks per month . [doctor] that's correct . [patient] take a look at your hip . [doctor] okay . [patient] please use my general physical exam template . physical exam miss reyes is a pleasant 56-year-old woman who is 5 feet 6 inches in height , weighing 169 pounds , [doctor] blood pressure is 115/75 . pulse rate is 67 . ankles , no ankle edema is noted . no calf tenderness . okay miss reyes , can you go ahead and stand up for me please and take a couple of steps . [patient] great and can you walk on your tippy toes ? [doctor] good , okay and can you walk on your heels , kind of a heel walk and toe walk are intact . go ahead and turn around please . okay . examination of the cervical spine , any pain here now ? [patient] no . [doctor] okay . no tenderness . look at your right and your left and then over to the right . then go ahead and look up and look down and look straight ahead range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ? [patient] no . [doctor] okay . skin is intact . no midline tenderness to palpation . go ahead and lean back and lean to your right to your left . does that hurt at all ? no . [patient] okay , great and go ahead and bend forward and then come back up and that does n't bother you ? [doctor] no , i did or do have several bulging disks . [patient] okay , but you're not hurting right now ? [doctor] no , the weight loss has really decreased all the pain . okay . range of motion is decreased in exertion . lateral flexion without pain . any pain when i push ? [patient] no . okay . you can go ahead and sit down please . no pain ? [doctor] no . [patient] okay . sacroiliac signs are negative . examination of the hips , [doctor] trochanteric is nontender . go ahead and lift your knee up . does that bother you ? [patient] just a little bit . [doctor] okay . little bit and then back one probably bothers you ? right there like the area . [patient] okay . how about this way ? not too bad ? [doctor] no . okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . [patient] okay , go ahead and keep it up , do n't let me push it down . does that hurt ? right there . okay . resisted right hip flexion causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ? [doctor] yeah . okay . motor control is normal in the lower extremities . go ahead and lift your knee up . [patient] okay . [doctor] okay . lift it up , any pain ? [patient] no . [doctor] okay and this one ? [patient] yeah . [doctor] and squeeze your knees together push it out and kick your leg out straight now go ahead and bring it back and kick it out straight again and go ahead and lean back , keep it loose okay all set and go ahead and sit up now okay , thank you . [patient] you're welcome . so what i think we're dealing with is right hip degenerative joint disease . [doctor] okay . [patient] and we do have some options , so first is to start some low impact exercises . i can provide you with a handout with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain . [doctor] i do n't love that idea , but i will give it a try . [patient] okay , that would be great and we can also try a cortisone injection into the right hip joint to see if that offers any relief . [doctor] i would like to definitely get that injection . [patient] okay . we can take care of that today while you are here and then schedule a follow-up appointment in 3 months to see how you are doing and then receive another injection if needed . [doctor] okay that sounds good . [patient] okay and here are the risks associated with getting the injection please just take a moment to review it and consent to the shot . [doctor] i'm good . [patient] great . we'll get that set up for you . alright , well i hope things feel better and we will see you back here in 3 months . [doctor] thank you . have a nice day . [patient] thank you so much , you as well . [doctor] deep tendon reflexes 1+ throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list . [patient] next radiographs , mr arthrogram of the right hip done june 3 , 2021 show high grade chondromalacia involving the anterosuperior right acetabulum , with subchondral marrow edema and cyst formation . , plan , options include low impact exercise program , use of an nsaid and use of the cane to offload the right . we discussed that she'd like to proceed with a cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile , and covid . she understood and decided to proceed with the injection . [doctor] she will follow up with me in 3 months for another injection if needed . end of dictation .

CHIEF COMPLAINT

Right hip pain.

HISTORY OF PRESENT ILLNESS

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

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

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

Opioid Assessment

Opioid Use: No.

Pain Assessment

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

PAST HISTORY

Medical
PCOS.

Surgical
Cholecystectomy.

SOCIAL HISTORY

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

FAMILY HISTORY

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

CURRENT MEDICATIONS

NSAID PRN by mouth.

ALLERGIES

Percocet.
Vicodin.
Reglan.

VITALS

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

PHYSICAL EXAM

Constitutional
Pleasant.

Integumentary
Skin is in tact.

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

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

RESULTS

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

ASSESSMENT

• Right hip degenerative joint disease.

PLAN

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

INSTRUCTIONS

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


[doctor] dictating on donald clark date of birth 03/04/1937 . chief complaint is left arm pain . hello , how are you ? [patient] good morning . [doctor] it's nice to meet you . i'm dr. miller . [patient] it's nice to meet you as well . [doctor] so i hear you are having pain in this arm , is that correct ? [patient] that's correct . [doctor] okay and it seems like it's worse at night ? [patient] well right now the hand is . [doctor] mm-hmm . [patient] and the thing started about 2 weeks ago , i woke up about 2:00 in the morning and it was just hurting something awful . [doctor] uh uh . [patient] and then i laid some ice on it and it finally did ease up . [doctor] okay , that's good . [patient] so i got up , i sat on the side of the bed and held my arm down thinking it would like help the circulation , but it did n't . [doctor] okay , i see . [patient] and so after a while when it eased off maybe about four or 5 am i laid back down and it did n't start up again . [doctor] mm-hmm okay . [patient] i went back to sleep but for several nights this happened like over and over , so i finally went to see the doctor and i do n't really recall her name . [doctor] okay . yeah , i think i know who you're talking about though . [patient] she is the one who sent me to you , so i , i would , i would think so , but when i went to her after the third time it happened , then she checked me out , she said it was most likely coming from a pinched nerve , [doctor] probably do you notice that moving your neck or turning your head seems to bother your arm ? [patient] no . [doctor] okay . is moving your shoulder uncomfortable at all ? [patient] no . [doctor] and do you notice it at other times besides during the night ? [patient] some days if it bothers me at night , then the day following it usually will bother me some . [doctor] okay and do you just notice it in the hand or does it seem to be going down the whole arm ? [patient] well it starts there and goes all the way down the arm . [doctor] okay . have you noticed any weakness in your hand at all ? [patient] yes . [doctor] okay like in terms of gripping things ? [patient] yeah . [doctor] okay . [patient] this finger i hurt it sometime ago as well . [doctor] really ? [patient] yeah , it does n't work properly or it works very rarely . [doctor] gotcha and did i hear that she gave you some prednisone and some oral steroids or ? [patient] well she gave me some numbing medicine , it helped a little bit . the other two were a neck pill and gabapentin , [doctor] you should have a full list in your notes though since then it has n't really bothered me at night also just see now i am a va and him 1 % disabled from this leg issues from the knees down to my feet okay is it neuropathy gotcha , that is good to know . alright , well , let's go ahead and take a look . [patient] okay . [doctor] alright , so to start , i'm gon na have you do something for me just go ahead and tilt your chin as far as you can down to your chest . okay , good and now go the other way , tilting your chin up as far as you can . now , does that seem to bother you at all ? okay and now come back to normal , just look and turn your head as far as you can that way great and now as far as you can towards that wall , does not seem to bother you at all now well actually i do feel little strain okay so you feel it in the neck a little bit yet is a little strain okay now squeeze my fingers as hard as you can with both hands great now hold your arms like this . [patient] okay . [doctor] and i'm going to try to straighten your arms and try and keep them as stiff as you can , do n't let me straighten it . okay , good , good . now when i am just touching your hands like this , does it seem to feel about the same in both hands ? [patient] yes . [doctor] okay . alright so i do agree with betty more than likely this seems like it would be coming from your neck that's the most common reason that causes what what you're experiencing . and i looked at an x-ray of your neck and you do seem to have a lot of arthritis there and there does seem to be potential for a disc to be pushing on a nerve . and now what i do n't have is an mri which would show me kind of exactly where the nerve roots are getting pinched off . [patient] i see . [doctor] so gabapentin can help a little bit with the nerve pain and what i would like to do is potentially set you up for an epidural and what that is is it it's a focused anti-inflammatory medicine excuse me , that works behind the nerve roots , that nerve roots that we are thinking might be getting squished off . it can often help alleviate your symptoms and i do need to get an mri of your neck . i know we have had one of your lower back , but i need one of your neck to see exactly where the roots are getting pinched off . so what i can do is tentatively set you up for an epidural , but before you do that , we do need to get that mri so i can see . right where i need to put the medicine for your epidural . what do you think of that ? [patient] i think that sounds good to me . [doctor] okay , good and just to confirm , do you take any blood thinners ? i do n't think i saw any on your medicine list . [patient] no , i do n't . [doctor] okay good and what i would have you do is continue with the gabapentin are you taking 300 or 100 ? [patient] i'm not sure my lady friend helps me handle this stuff . [doctor] okay . [patient] i am taking eliquis though . [doctor] okay so whatever you are doing , you can just keep doing it and i'm going to set you up for the epidural and imaging study just so i know right up with the medicine and i will follow up with you after that and we can do the shot just to make sure your arm is feeling better sound good . [patient] sounds good . for the last couple of nights though my neck has not been bothering me . [doctor] okay so presumably what's happening then is when you're sleeping , your neck is kinda gets off tilt tilter and it compresses the nerve roots there . now if you think you're doing fine , we could hold off , but at the very least , i'd like to update that mri of yours and see what's going on because probably this is something that will likely flare up again . [patient] yeah it it has been for the last week , so i understand . okay , alright , well , do you want to do that work-up and do the epidural or do you think you're doing fine and do you wan na wait ? well my hand is still bothering me . okay . so you're saying your neck is not bothering you , but the hand is . okay , so then let's just stick with the plan . [doctor] mri of the neck , so we can see where the nerve roots maybe compressed that's giving your hand the issue and then we are going to set you up with the epidural . [patient] okay , sounds good . [doctor] alright , so keep going with the gabapentin . i will order the imaging of your neck and the shot will hopefully help some with those symptoms in your hand and then we will follow up afterwards . [patient] alright , is the mri today ? [doctor] you probably ca n't do it today , but let me talk with roy and see how soon we can get it done . just give me a quick minute and then roy will come in and get things scheduled as soon as we can . alright . [patient] alright , well , it was nice meeting you my friend . [doctor] you as well , thank you . physical exam , elderly white gentleman presents in a wheelchair , no apparent distress per the template down through neurologic , 1+ bilateral biceps , triceps , brachioradialis , reflexes bilateral , all negative . follow up and take out the lower extremities . gait not assessed today . strength and sensation is per the template . upper and lower extremities , musculoskeletal , he is nontender over his cervical spine . he does have mildly restricted cervical extension , right and left lateral rotation which is symmetric which gives him mild lateral neck pain , but no radic radicular pain . spurling's maneuver is benign . paragraph , diagnostics , cervical x-rays 6/4/2021 . cervical x-ray reveals significant disc degeneration at c5-6 and to a lower extent c4-5 and c3-4 . significant lower lumbar facet arthropathy c6-7 and c7-t1 is difficult to visualize in the current x-rays . paragraph , impression , # 1 , left upper extremity neuropathy suspicious for cervical radiculopathy , possible contribution of peripheral neuropathy . # 2 , neck pain in the setting of arthritis , disc degeneration . paragraph , plan , i suspect that this is a flare of cervical radiculopathy . i'm going to set him up for a cervical mri and we'll tentatively plan for a left c7-t1 epidural afterwards , although the exact location will be pending the mri results . he'll continue his home exercise program as well as twice a day gabapentin . we'll follow up with him afterwards to determine his level of relief . he denies any blood thinners .

CHIEF COMPLAINT

Left arm pain.

HISTORY OF PRESENT ILLNESS

He reports that his left arm pain began approximately 2 weeks ago. He woke around 2:00 am with intense pain in his left arm and hand. He applied ice and after 2-3 hours, the pain improved and he was able to go back to sleep, the pain did not return until that evening. After several nights of experiencing the left arm and hand pain, he was seen by Betty Ross, PA-C. She suspected a pinched nerve and completed x-rays of the cervical spine, prescribed gabapentin and prednisone, and referred the patient to us. The patient has benefited from the gabapentin and prednisone, reporting improvement of pain at night.

The pain initially was encountered at night, but the patient notes that the symptoms carry into the next day. He denies pain when moving his neck, turning his head, and moving his shoulder.

Mr. Clark does report a history of a left finger injury, stating “it rarely works”, and neuropathy in one leg from his knee to his foot which he receives 1% disability for. The patient is a veteran.

PAST HISTORY

Medical
Peripheral neuropathy.

SOCIAL HISTORY

The patient is a veteran and receives 1% disability.

CURRENT MEDICATIONS

Gabapentin tablet.
Prednisone tablet.

PHYSICAL EXAM

Constitutional
Elderly Caucasian male in no apparent distress. Presents in wheelchair.

Neurologic
Upper extremities: 1+ bilateral biceps, triceps, brachioradialis, reflexes bilaterally, negative. Negative Hoffman's
Gait: Not assessed today.

Strength
Upper extremities: Normal throughout the biceps, triceps, deltoid, grip strength, and finger abduction, bilaterally.
Sensation: Intact to light touch throughout the upper and lower extremities.

Musculoskeletal
Cervical: Nontender over cervical spine. Mildly restricted cervical extension and right and left lateral rotation, which is symmetric, which gives him mild lateral neck pain, but no radicular pain. Spurling's maneuver is benign.

RESULTS

X-ray Cervical Spine, 06/04/2021.
Impression: Significant disc degeneration at C5-6 and to a lesser extent C4-5 and C3-4. Significant lower facet arthropathy. C6-7 and C7-T1 are difficult to visualize in the current x-rays.

ASSESSMENT

• Left upper extremity neuropathy, suspicious for cervical radiculopathy, possible contribution of peripheral neuropathy
• Neck pain in the setting of arthritis and disc generation

PLAN

I suspect that this is a flare of cervical radiculopathy. I am going to set him up for a cervical MRI. We will tentatively plan for a left C7-T1 epidural afterwards, although the exact level will be pending the MRI results. He will continue his home exercise program as well as twice daily gabapentin. We will follow up with him afterwards to determine his level of relief. He denies any blood thinners.

This plan was discussed in detail with the patient who is in agreement.

INSTRUCTIONS

Continue home exercise program and twice daily gabapentin. Schedule MRI and epidural injection. Follow-up after epidural.


[doctor] patient is pamela cook , medical record number is 123546 . she is a 36-year-old female post bilateral reduction mammoplasty on 10/10/2020 . doing well , it's good to see you , how you've been ? [patient] i've been doing good . [doctor] great how about your breasts today , doing alright ? great are you having any chills fever nausea or vomiting now good peak real quick sure how is life otherwise pretty good nothing new just enjoying summertime okay how is your family ? [patient] very good . [doctor] good alright i'm gon na take a look at your breast now if you would just open up your gown for me everything looks good has her back pain i'm not really having any more any hard spots lumps or bumps that you've noticed i did when i came in last time when i saw your pa ruthsanchez in march she said i she said she found a lump right here under my left breast but i have n't felt it since then but i did the massages echo that that is good is probably just a scar tissue but everything looks good and your healing wonderful so i told her that the scar here was kind of bothering me and i got forgel i was using it every day but i do n't think i needed now yeah , that scar did widen a little bit . lem me take a closer look . hang on . this one widened a little too uh . your incisions are well healed though with no signs of infection or any redness on either breast , so i'm not concerned . but this one just bothered me a little bit more understanding culture gown now the only thing that is really going to help out that is to to cut it out and re close it . [patient] [doctor] and you do n't want that uh ? [patient] i mean not right now . [doctor] you want to come back and revisit maybe 6 months yet ellipta that i still have n't i still have some more of the gel and i can try using that again okay . keep doing that twice a day , the gel is going to lighten the color a little bit which is already pretty light but just in that area and it's it's high tension so it's going to rub a little bit . [patient] yeah but it kind of bothers me a little bit . [doctor] i do see that like i said the only way to really fix that is to cut it out with a 6 months and then will go from there semi a plan but we have n't had a full year yet i know i would n't do any revisions anyway for scar tissue until we're at least a year out anyway . [patient] okay . [doctor] so let's wait those 6 months , you can keep using the mederma scar gel twice a day , massage and scar gel will help for the scars . you can put it on other scars too if you need . [patient] okay . [doctor] so that's what i would do . let's just get some pictures today , so we can keep up with them and keep an eye on this scars and then we will go from there . [patient] sounds good . [doctor] alright , well it's good to see you , i'm glad you're doing well . [patient] yeah , same here . [doctor] alright , well , i'm gon na tell the front desk 6 months and we'll revisit those scars . [patient] alright . [doctor] thank you . i'm gon na come and get your photos now , okay ? [patient] okay .

CHIEF COMPLAINT

Follow up bilateral reduction mammoplasty.

HISTORY OF PRESENT ILLNESS

Pamela Cook is a 36-year-old female who is returning for a postoperative visit. Status post bilateral reduction mammaplasty 10/10/2020.

The patient was last seen in clinic by Ruth Sanchez, PA in 03/2021 at which time there was a lump along the left breast, and she was advised to perform massages.

Today, Ms. Cook reports she is doing well and that her breasts feel great. She is no longer suffering from back pain. The left breast lower incisional lump from last visit has resolved with massaging and use of scar gel. She reports that the scar on her breast has been bothersome. The patient denies fever, chills, nausea, or vomiting.

CURRENT MEDICATIONS

Mederma scar gel to incision.

PHYSICAL EXAM

Breast
Bilateral breast incisions well healed with widening of the scar tissue. No signs of infection or erythema.

ASSESSMENT

• Status post bilateral reduction mammoplasty.

Pamela Cook is a 36-year-old female who is status post bilateral reduction mammaplasty on 10/10/2020. There is some widening of the scar tissue bilaterally.

PLAN

- Obtain bilateral breast photos today to monitor scarring.
- Continue Mederma scar gel and incisional scar massage twice daily.

INSTRUCTIONS

Follow up in 6 months to reevaluate scars.


[doctor] next patient is paul , date of birth is january 15 , 1962 . this is a 59-year-old hiv positive gentleman here for hypogonadism . patient was last seen on november 24 , 2020 . he is . [patient] his notable things are # 1 , he is on 1 ml every 10 days . his levels were less than 300 to begin with . he is on finasteride currently . he also takes cialis daily , so he takes all his pills just from me , patient's other area of concern is gynecomastia , which is , which we will discuss with him today . his last psa was 0.66 and his last testosterone was greater than 1500 . [doctor] hey , how are you today ? [patient] alright , how you been ? [doctor] i'm good . [patient] good , good . [doctor] have you lost some weight or you at least putting on some muscle , you look trump . [patient] no , i think i'm pretty much the same as i've always been . [doctor] really ? okay , maybe it's just your black shirt , makes you look then . [patient] yeah , i guess that's it . [doctor] so health wise , how is everything going ? [patient] good , the testosterone is going well . [doctor] that's great . [patient] helped me out , i feel good , more vigorous , sleeping well and i think it's having some positive effects , not so much physically because like i said , i've i've been this way my whole life , but i'm seeing some good improvements in my blood work . [doctor] okay , well , that's good . [patient] so the finasteride i am only taking half a pill , it's the 5 mg one . [doctor] yeah , i remember you telling me that . [patient] and cialis on the days i work out , i take 5 mg , otherwise i take 2-1/2 mg pills , but i have been out of it . [doctor] okay . [patient] but overall i'm doing well . i'm actually taking the correct steps to get my life together . [doctor] good . it's always great to hear . let's look i'm gon na listen to your heart and lungs . [patient] okay . [doctor] please use my general exam template alright just take a few breaths . [patient] okay . [doctor] now . alright everything sounds good , no concerns there . [patient] great . so i wanted to show you something . [doctor] sure . [patient] look at this . [doctor] okay , this is your cholesterol . [patient] yeah , my cholesterol and triglycerides , i used to have high triglycerides , you see they were 265 mg/dl , then i took my first dose of the testosterone on the 28th . [doctor] right . [patient] now 5 months later look at my numbers . [doctor] wow , that's remarkable . [patient] this is the test , it's the only change . i do n't know , i have n't honestly seen many guys over the years that have cholesterol problems and this i mean there is a big correlation between diabetic control and testosterone replacement meaning those who get good levels of their tests see their diabetic control improve . [doctor] yeah . but i have n't seen a lot of data on the impact on cholesterol . regardless we will take it . [patient] i agree . i was very impressed with my triglycerides and was just wondering if the test may be what's helping . [doctor] yeah , that's an unbelievable difference . [patient] 145 mg/dl from 265 mg/dl is awesome . i also read that it it's cardioprotective . [doctor] absolutely . [patient] my red blood cell count has increased . [doctor] yeah , i saw that . it's fine though . [patient] stable . [doctor] your psa a today is also is good also . it's 0.6 i think . [patient] yeah is it ? [doctor] yeah , it was 0.5 last year and anything under four is good . [patient] nice , such good news . [doctor] so it just needs to be checked every year or so . [patient] so in terms of estrogen control , i've been hearing that indol three carbonal or broccoli extract , supposedly can improve my estrogen levels . have you ever heard of it ? yeah , i've heard of it , but i have n't had anybody consistently use it . i mean your levels are fine and we checked your estradiol and it was not elevated , so . okay . [doctor] i would argue that we could test that in the fall if you want , but we do n't need to do anymore tests anymore than test once a year , excuse me . [patient] okay . what about increasing my testosterone to 175 mg . i'm at 140 now . [doctor] well , your levels are high . [patient] are they right now ? [doctor] well , i mean they were last time . [patient] yeah , but i just just injected though where i had right before that was taken . [doctor] i know , i know you had then . when did you inject this time ? [patient] i figured i'm on my eighth day today . [doctor] okay . [patient] so i'm due to dose on thursday or friday . [doctor] alright . [patient] i have a little med calendar and i put checks and teas on it , that helps me . [doctor] that's a great idea . so look the biggest issue i've seen even if your levels today are around 700 is that your peaks are getting greater than 1500 , putting you at a higher chance of needing to come off due to blood thickness and your risk will only go up the higher the dose that we go on . [patient] okay . [doctor] you look well , your levels are good and you are feeling well . [patient] yeah , i'm feeling good . [doctor] i'm going to be blunt . unfortunately this happens often where you are feeling good but you want to feel really good . i mean i get it , and this is why people get into problems with this stuff , right ? it's like back in the day when it was n't prescribed by doctors and people would get it at gyms and stuff and they would take huge doses and then they would have a heart attack at 50 . [patient] yeah , they have to be taking a lot . [doctor] likely they are taking more than testosterone but still . [patient] and they are taking stuff for a long time . [doctor] true but right now i would not change your dose . [patient] okay . [doctor] makes sense ? [patient] it does , i appreciate the discussion . [doctor] no problem . what pharmacy are you using ? have you changed it or anything ? [patient] no changes , i use walmart pharmacy . i do need more cialis and finasteride . [doctor] okay . [patient] i would prefer the paper prescription . [doctor] for all of them ? [patient] sure . [doctor] alright , we will do . let me go get your prescriptions . [patient] okay , thank you .

CHIEF COMPLAINT

Hypogonadism.

HISTORY OF PRESENT ILLNESS

Mr. Paul Edwards is a 59-year-old male, an established patient, who presents to the clinic today for hypogonadism. He was last seen on 11/24/2020. The patient’s history includes positive for HIV, and today he is concerned with gynecomastia.

The patient is doing well, overall, and feels the testosterone is helping. He reports weight stability, feels lively, good, more vigorous, and he is sleeping well. He also thinks the testosterone is having a positive effect on his blood work. He endorses that his triglycerides have always been elevated and adds that they were as high as 265 mg/dL. The patient presented a copy of his bloodwork, showing a significant decrease in his cholesterol after 5 months. Mr. Edwards questioned if the changes in his blood work were due to the testosterone. He also noted that his red blood cell count has not increased. The patient inquired about possible benefits of Indole-3-carbinol, which is a broccoli extract for estrogen control.

Currently, the patient is dosing 140 ng/dL of testosterone per week and inquired if his dose could be increased to 175 ng/dL. He recalled that he had recently injected testosterone before his last testosterone blood work was performed; last testosterone levels were greater than 1500 ng/dL. The patient confirms continued daily use of Finasteride and Cialis, prescribed by me, and stated he needs a refill for both.

Mr. Edwards mentioned he is taking correct steps to get his life "together." He also uses a med calendar to help with medication compliance.

PAST HISTORY

Medical
HIV

SOCIAL HISTORY

Utilizes med calendar to support medication compliance.
Actively trying to get his life together.

CURRENT MEDICATIONS

Cialis 5 mg tablet by mouth on days he exercises, 2.5 mg tablet by mouth on days without exercise.
Finasteride 5 mg half tablet daily.
Testosterone cypionate 140 mg.

RESULTS

PSA 0.6 ng/mL.
Triglycerides 145 mg/dL.
Total testosterone 1500 ng/dL, 11/24/2021.

ASSESSMENT

• Hypogonadism.

PLAN

I recommend maintaining current management. The patient’s last testosterone levels were greater than 1500 ng/dL, although this level was likely related to his recent injection. He requested an increase to his testosterone cypionate from 140 mg to 175 mg, which I denied due to his already high testosterone levels. I counseled the patient on the risks associated with high testosterone levels and Indole-3-carbinol and it’s lacking evidence to support his estrogen levels. The last time his estradiol levels were checked, they were normal; recommend annual screening.

I provided paper prescription refills for Cialis and Finasteride.