[doctor] okay raymond it looks like you've been having some difficulty swallowing over for a period of time could you tell me like what's going on
[patient] well i've been better for the last several weeks i've been noticing that it's been hard for me to swallow certain foods and i also have pain when i swallow down in my chest
[doctor] okay and when does it does it happen every time you eat
[patient] it hurts not every time it hurts when i when i swallow most foods but it's really just the bigger pieces of food that seem like they're getting stuck
[doctor] okay and what do you mean by bigger pieces of food like what's your diet like
[patient] well things have been stressed over the last couple of months so lacks a moving from the west coast of east coast so i've been drinking more eating things like pizza burgers i know it's not good but you know it's been pretty busy
[doctor] wow that sounds kinda stressful like what are you moving for
[patient] well i'm stressed because what i'm moving because you know i i do n't like the west goes so i i decided to move but you know it's just stressful
[doctor] uh uh
[patient] because i do n't know how my dog is gon na handle the travel but i do n't wan na put them into the carbo portion of the plane we fly out of her really bad stories of dogs got in the wreck
[doctor] okay so are you thinking of driving
[patient] i i think so i think i'm i think i'm gon na end up driving but that's still a a long trip
[doctor] yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms
[patient] no i wish unfortunately i've gained some weight
[doctor] okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea
[patient] sometime my belly hurts up here
[doctor] okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool
[patient] not that i noticed
[doctor] okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt
[patient] no i did that hurts
[doctor] okay pain to palpation of epigastric area how about now
[patient] no
[doctor] okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for your i reviewed the results of your barium swallow and it showed that you have two areas of mild narrowing in the mid and lower portions of your esophagus that can be found in patients experiencing something called esophagitis so for your primary primary problem you have acute esophagitis i wan na go ahead and prescribe protonix it's forty milligrams you're gon na take that once a day you should take it the first thing in the morning i also wan na prescribe to you something called carafate you take one gram four times a day for one month that's just gon na help kind of coat your the in the lining of your esophagus and like your stomach so that you're again like not producing a whole lot of acid like your your pretty much your the acid in your stomach is getting where it does n't need to be and it's a bit too strong so we're gon na give your body time to do a reset i wan na schedule you for an upper endoscopy just to be sure we are n't missing anything else i encourage you to change your diet and decrease alcohol and caffeine i know that's gon na be pretty hard with the move but you know once especially once you're settled in it's gon na be very important for us to to like focus on like getting well and eating healthy so that you know like you can you can move about your day as best as you can and and enjoy your move i want you to consider like eating slowly and chewing your food more thoroughly so that you do n't have to deal with those big pieces i also want you to avoid citrus foods fruits and spicy foods until your symptoms have improved i wan na see you again next week for that endoscopy i know there was a lot of information do you have any questions
[patient] no i think that's all good
[doctor] okay alright thank you so much for coming in

CHIEF COMPLAINT

Difficulty swallowing.

HISTORY OF PRESENT ILLNESS

Raymond Taylor is a pleasant 67-year-old male who presents to the clinic today for difficulty swallowing. The patient notes that the pain has been occurring for the last several weeks. The pain radiates to his chest when he swallows. He notes that he does not have pain every time he eats but mostly when he has big pieces of food as they seem to get stuck. Mr. Taylor notes that it has been stressful for him the past couple of months as they moved from the West Coast to the East Coast, so he has been drinking more, and having pizza, and burgers more. He denies any weight loss, but endorses weight gain. The patient states that he has epigastric pain, but denies dark, tarry stools.

REVIEW OF SYSTEMS

Constitutional: Reports weight gain.
HENT: Reports dysphagia.
Gastrointestinal: Reports epigastric pain. Denies dark, tarry stools.
Neurological: Positive stress.

VITALS

BP: 133/70.
Heart rate looks good.
Temperature is within normal limits.
SpO2: 100%.
Respiratory rate: 19.

PHYSICAL EXAM

EYES: Equal and reactive to light.
NECK: No adenopathy, thyromegaly.
RESPIRATORY: Normal respiratory effort no respiratory distress
GI/GU: Non-distended Active bowel sounds. Pain to palpation of epigastric area. Negative McMurphy's Sign. No peritoneal signs. No rebound.
SKIN: No rash, no lesion, no bruising.
MSK: Examination of the mouth reveals no obvious ulcers or evidence of thrush present. Tonsils are midline of the neck.

RESULTS

The barium swallow study revealed two areas of mild narrowing in the mid and lower portions of your esophagus.

ASSESSMENT

Acute esophagitis.

PLAN

After reviewing the patient's examination and barium swallow findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have prescribed the patient Protonix 40 mg first thing in the morning to treat his acute esophagitis. I have also prescribed the patient Carafate 1 gram 4 times daily for 1 month to help coat the lining of his esophagus and stomach. I recommended a upper endoscopy for further evaluation. I have also advised him to change his diet, decrease alcohol, and caffeine. I have also advised him to avoid citrus foods, fruits, and spicy foods until his symptoms have improved. We discussed that he should eat slowly and chew his food thoroughly to avoid big pieces of food. All questions were answered.

INSTRUCTIONS

The patient will follow up with me in 1 week for his endoscopy.


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

HISTORY OF PRESENT ILLNESS

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

The patient has a history of a left leg injury.

REVIEW OF SYSTEMS

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

PHYSICAL EXAM

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

RESULTS

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

ASSESSMENT

Right foot pain, consistent with a Lisfranc fracture.

PLAN

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


[doctor] hey diana it's good to see you in here so i see that you injured your wrist could you tell me a bit about what happened
[patient] yeah i was walking up and down the stairs i was doing my laundry and i slipped and i tried to catch myself and i put my arms out to catch myself and then all of a sudden i just my wrist started to hurt real bad and it got real swollen
[doctor] wow okay so which wrist are we talking about left or right
[patient] it's my right one of course
[doctor] okay and then have you ever injured this arm before
[patient] no i have not
[doctor] okay alright so on a scale of one to ten how severe is the pain
[patient] gosh it's like a nine
[doctor] wow okay have you done anything to ease it
[patient] yeah i did the ice thing i put ice on it and then i you know i even i have a ace wrap at home i try to do that
[doctor] mm-hmm
[patient] and then i took some ibuprofen but it helps a little bit but it's just it's it's just not right
[doctor] okay
[patient] really
[doctor] yeah okay have you sorry i'm trying to think how long ago did this injury happen
[patient] this happened yesterday morning
[doctor] okay
[patient] maybe just you know i just bumped it but
[doctor] okay
[patient] it's just not it's really bad
[doctor] okay no i understand okay so i'm going so you said you were doing laundry
[patient] yes i had my back hit my basket and for some reason this cold started to kinda fall out a little bit i was trying to catch it i missed a step and i just totally
[doctor] okay alright any does the pain extend anywhere
[patient] no not really
[doctor] okay
[patient] it's just really along my wrist
[doctor] okay any numbness any tingling
[patient] a little one and one ca n't tell if it's just because of the swelling in my wrist but just i can like i can feel it my fingers still
[doctor] mm-hmm
[patient] but just maybe a little bit of tingling
[doctor] okay alright and are you so so okay i'm gon na think on this but in the meantime i'm gon na do my physical exam alright
[patient] okay
[doctor] okay so you know looking at your looking at your head and your neck i do n't appreciate any like adenopathy no thyromegaly no no carotid bruit looking at your listening to your heart i do n't appreciate any murmur no rub no gallop your lungs are clear to auscultation bilaterally your lower legs you have palpable pulses no lower edema your shoulders every like your upper extremities i see normal range of movement with your right wrist let's go ahead and focus on it so when i push on the inside here does it hurt
[patient] yes
[doctor] okay
[patient] it does
[doctor] and what about the outside does that hurt as well
[patient] yeah it does
[doctor] are you able to move your wrist towards your arm like
[patient] not without extreme pain
[doctor] okay so pain on flexion what about extension when you pick your wrist up
[patient] yeah i have a hard time doing that actually
[doctor] alright what about we're gon na go ahead and hold your arm like straight like flat and then try and move it sideways does radial deviation hurt
[patient] yeah
[doctor] alright and then lateral as well
[patient] yeah it's really hard to move any direction of this hand for some reason
[doctor] alright so wrist abduction adduction positive for pain on movement are you able to make a fist
[patient] hmmm yeah a little bit but i ca n't do it really tight
[doctor] okay alright okay so i'm just gon na go ahead and feel on your fingers really quickly alright metacarpals intact noticed some obvious swelling ecchymosis obvious swelling and bruising tenderness on palpation throughout there is evidence of potential fracture feeling some bony crepitus alright so this pain is it like chronic i wanted to ask you
[patient] yeah i would say it kinda goes away when i take that ibuprofen but for the most part i feel it i feel it there and it it's just really really bad when i move it all
[doctor] okay so when you like is there a position either hurts less or hurts more like say if your arm is raised and elevated over your head does it hurt more or is it just best to keep it like down
[patient] it's good if i keep it a little bit above my like a little i guess a little bit like around my like just a regular level like if you're typing or something and then i just put it on a pillow and i just let it stay straight like i feel better
[doctor] okay yeah no i do n't think i understand completely okay so i took a look at your vitals and your blood pressure is a little elevated but honestly that's probably to do with the pain right our body can respond to pain in that way we are looking at like a hundred and forty over over seventy it's not anything crazy but something to mention i see that your heart rate is also a little elevated at like about like eighty beats a minute you are not running a fever so that's great look at ninety ninety seven . two your respiratory rate is pretty normal at like twenty so before we came in i i know that we had you do an x-ray and i'm sure that that was a bit more painful because we had to do so many manipulations but i do wan na note that you are positive for what we call a colles' fracture what that means is that the joints between your wrist like the bones between your wrist that there there is evidence of a a fracture and we are gon na have to treat it a little conservatively at first and then consider some of the options options that are available to us so for your primary diagnosis of a colles' fracture we are going to give you a thumb spica for today and that's going to
[patient] i'm sorry
[doctor] pardon what
[patient] a what
[doctor] we're gon na brace you we're gon na give you a brace
[patient] okay thank you
[doctor] sorry no problem sorry yeah not a thumb spica we're gon na brace your arm and you're gon na have that we we have a couple of options but i think the best course of action is gon na be for surgery we will in the meantime give you pain medication i wan na put you on fifty milligrams of ultram every six hours and then i also wan na get you on get you into physical therapy a few weeks after surgery this is gon na be just a normal procedure you will be in for an overnight stay but after that once we assess and make sure that everything is good you'll be able to go home okay
[patient] when do i have to have the surgery
[doctor] we would like it to happen as quickly as possible you know your body is a wonderful miracle and it's going to start trying to heal on it's own what we need to do is get your wrist straight and then like put screws in to make sure that we hold it in place or else it could like heal and malform
[patient] okay
[doctor] alright so what
[patient] how how long do i have to wear that brace
[doctor] you're gon na be wearing the brace for about six weeks
[patient] six weeks
[doctor] yeah so you're gon na you're gon na come in for your surgery we're gon na perform it you're gon na stay overnight and then you'll be bracing it for six weeks in the meantime you'll also then go to physical therapy i want you there like we're gon na they're gon na do an assessment and determine how much but i'm thinking probably three times a week just to make sure that you can get your wrist as strong as possible to prevent like future injury now the cool thing about getting any kind of a bone break is that your your body comes out even stronger so this should n't happen again but unfortunately like it's these situations that oof that just kind of
[patient] oof
[doctor] these these deform these deformities that really that really kind of hurt is the short version alright no problem any other questions
[patient] no well i am going on vacation do i need to cancel it like can i still go even with the i mean after the surgery
[doctor] yeah
[patient] do it as soon as possible i'm going a vacation in a month so
[doctor] okay how long is the vacation
[patient] it's only for like a couple weeks
[doctor] okay well so you might have to postpone it just because depending on what physical therapy says right if they feel that you can sustain if you can like sustain the exercises while you're gone that if there's something that you can do by yourself then you should be fine but we do wan na give it you said that it's gon na happen in a couple of weeks
[patient] no vacation in a month
[doctor] okay okay yeah so how about in a month we come you come back let's do a checkup again see where we are at and then we can assess whether or not this is something that i would recommend you do
[patient] that sounds good thank you
[doctor] no problem bye
[patient] bye
[doctor] the fracture appears extra-articular and usually proximal to the radial ulnar joint dorsal angulation of the distal fracture fragment is present to a variable degree if dorsal angulation is severe presenting with a dinner fork deformity ulnar styloid fracture is present

CHIEF COMPLAINT

Right wrist injury.

HISTORY OF PRESENT ILLNESS

Diana Scott is a pleasant 61-year-old female who presents to the clinic today for the evaluation of a right wrist injury. The patient sustained this injury yesterday morning, 05/12/2022, when she slipped on the stairs while carrying a laundry basket. She states she tried to catch herself with her arms outstretched. The patient reports an immediate onset of pain and swelling in her right wrist. She denies any previous injuries to her right arm. The patient rates her pain level as a 9/10. Her pain is aggravated by movement. The patient also reports numbness and tingling in her fingers. She has been icing and wrapping her right wrist with an ACE wrap. The patient has also been taking ibuprofen, which provides some relief. She notes fully extending her arm while resting it on a pillow alleviates some of her pain as well.

The patient is going on vacation in 1 month.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right wrist pain and swelling.
Neurological: Reports numbness and tingling to the digits of the right hand.

VITALS

Blood Pressure: Elevated at 140/70 mmHg.
Heart Rate: 80 beats per minute.
Respiratory Rate: 20 breaths per minute.
Body Temperature: 97.2 degrees F.
HEAD: Normocephalic
NECK: No swelling noted
CV: No bilateral lower extremity edema. No carotid bruit. No murmurs, gallops or rubs heard during auscultation of the heart. Palpabale pulses to the bilateral lower extremities.
RESPIRATORY: Normal respiratory effort no respiratory distress. Lungs clear to auscultation bilaterally.
GI/GU: Non-distended
BACK: No evidence of trauma or deformity
NECK: No adenopathy. No thyromegaly.
MSK: Examination of the right wrist: Limited range of movement. Tenderness to palpation. Pain on flexion and extension. Pain with radial deviation and lateral deviation. Pain with wrist abduction and adduction. The metacarpals are intact. Obvious swelling and bruising. Tenderness on palpation throughout. There is evidence of potential fracture feeling and bony crepitus.

RESULTS

X-rays of the right wrist were taken today. These reveal the fracture appears extra-articular and proximal to the radioulnar joint. Dorsal angulation of the distal fracture fragment is present to a variable degree. Dorsal angulation is severe, presenting with a dinner fork deformity. An ulnar styloid fracture is present.

ASSESSMENT

Right wrist Colles fracture.

PLAN

After reviewing the patient's examination and radiographic findings today, I have discussed with the patient that her x-rays revealed a right wrist Colles fracture. We discussed treatment options and I have recommended that we proceed with a right wrist ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I explained that we should schedule the operation for as soon as possible to ensure adequate healing and to limit malformation of the wrist. I advised that this procedure will require her to be admitted to the hospital for an overnight stay.

In the meantime, the patient will be placed in a thumb spica brace and receive instructions on its proper usage. I have prescribed the patient Ultram 50 mg every 6 hours to treat her pain. We also discussed that her postoperative course will include wearing a brace for 6 weeks. A few weeks after surgery, the patient will initiate formal physical therapy and will attend 3 times per week to strengthen her right wrist. The patient has a 2-week vacation planned in 1 month. I recommended that we consult with her physical therapist to determine if there are exercises she can perform on her own instead of postponing her vacation.

INSTRUCTIONS

The patient will follow up with me in 4 weeks status post surgery to discuss her progress.


[doctor] hi , martha . how are you ?
[patient] i'm doing okay . how are you ?
[doctor] i'm doing okay . so , i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ?
[patient] okay .
[doctor] martha is a 50-year-old female with a past medical history significant for congestive heart failure , depression and hypertension who presents for her annual exam . so , martha , it's been a year since i've seen you . how are you doing ?
[patient] i'm doing well . i've been traveling a lot recently since things have , have gotten a bit lighter . and i got my , my vaccine , so i feel safer about traveling . i've been doing a lot of hiking . uh , went to washington last weekend to hike in northern cascades, like around the mount baker area .
[doctor] nice . that's great . i'm glad to hear that you're staying active , you know . i , i just love this weather . i'm so happy the summer is over . i'm definitely more of a fall person .
[patient] yes , fall foliage is the best .
[doctor] yeah . um , so tell me , how are you doing with the congestive heart failure ? how are you doing watching your diet ? i know we've talked about watching a low sodium diet . are you doing okay with that ?
[patient] i've been doing well with that . i resisted , as much , as i could , from the tater tots , you know , the soft pretzels , the salty foods that i , i love to eat . and i've been doing a really good job .
[doctor] okay , all right . well , i'm glad to hear that . and you're taking your medication ?
[patient] yes .
[doctor] okay , good . and any symptoms like chest pains , shortness of breath , any swelling in your legs ?
[patient] no , not that i've noticed .
[doctor] okay , all right . and then in terms of your depression , i know that we tried to stay off of medication in the past because you're on medications for your other problems . how are you doing ? and i know that you enrolled into therapy . is that helping ? or-
[patient] yeah , it's been helping a lot . i've been going every week , um , for the past year since my last annual exam . and that's been really helpful for me .
[doctor] okay . so , no , no issues , no feelings of wanting to harm yourself or hurt others ?
[patient] no , nothing like that .
[doctor] okay , all right . and then in terms of your high blood pressure , i know that you and i have kind of battled in the past with you remembering to take some of your blood pressure medications . how are you doing with that ?
[patient] i'm still forgetting to take my blood pressure medication . and i've noticed when work gets more stressful , my blood pressure goes up .
[doctor] okay . and , and so how has work going for you ?
[patient] it's been okay . it's been a lot of long hours , late nights . a lot of , um , you know , fiscal year end data that i've been having to pull . so , a lot of responsibility , which is good . but with the responsibility comes the stress .
[doctor] yeah , okay , all right . i understand . um , all right . well , i know that you did a review of system sheet when you checked in with the nurse . i know that you were endorsing some nasal congestion from some of the fall pollen and allergies . any other symptoms , nausea or vomiting , abdominal pain , anything like that ?
[patient] no , nothing like that .
[doctor] no , okay , all right . well , i'm gon na go ahead and do a quick physical exam , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the blood pressure . so , yeah , looking at your blood pressure today here in the office , it is a little elevated . you know , it could just , you could just be nervous . uh , let's look at some of the past readings . hey , Sarah , show me the blood pressure readings . hey , Sarah , show me the blood pressure readings . here we go . uh , so they are running on the higher side . um , y- you know , i , i do think that , you know , i'd like to see you take your medication a little bit more , so that we can get that under control a little bit better , okay ?
[patient] okay .
[doctor] so , i'm just gon na check out your heart and your lungs . and you know , let you know what i find , okay ?
[patient] okay .
[doctor] okay . so , on your physical examination , you know , everything looks good . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which i've heard in the past , okay ? and on your lower extremities , i do appreciate one plus pitting edema , so you do have a little bit of fluid in your legs , okay ?
[patient] okay .
[doctor] let's go ahead , i wan na look at some of your results , okay ? hey , Sarah , show me the echocardiogram . so , this is the result of the echocardiogram that we did last year . it showed that you have that low-ish pumping function of your heart at about 45 % . and it also sh- shows some mitral regurgitation , that's that heart murmur that i heard , okay ?
[doctor] um , hey , Sarah , show me the lipid panel . so , looking at your lipid panel from last year , you know , everything , your cholesterol was like , a tiny bit high . but it was n't too , too bad , so i know you're trying to watch your diet . so , we'll repeat another one this year , okay ?
[patient] okay .
[doctor] um , so i wan na just go over a little bit about my assessment and my plan for you , okay ? so , for your first problem your congestive heart failure , um , i wan na continue you on your current medications . but i do wan na increase your lisinopril to 40 milligrams a day , just because your blood pressure's high . and you know , you are retaining a little bit of fluid . i also wan na start you on some lasix , you know , 20 milligrams a day . and have you continue to watch your , your diet , okay ?
[patient] okay .
[doctor] i also wan na repeat another echocardiogram , okay ?
[patient] all right .
[doctor] hey , Sarah , order an echocardiogram . from a depression standpoint , it sounds like you're doing really well with that . so , i'm , i'm really happy for you . i'm , i'm glad to see that you're in therapy and you're doing really well . i do n't feel the need to start you on any medications this year , unless you feel differently .
[patient] no , i feel the same way .
[doctor] okay , all right . and then for your last problem your hypertension , you know , again i , i , i think it's out of control . but we'll see , i think , you know , i'd like to see you take the lisinopril as directed , okay ? uh , i want you to record your blood pressures within the patient , you know , take your blood pressure every day . record them to me for like , about a week , so i have to see if we have to add another agent , okay ? 'cause we need to get that under better control for your heart failure to be more successful , okay ?
[patient] okay .
[doctor] do you have any questions ? , and i forgot . for your annual exam , you're due for a mammogram , so we have to schedule for that , as well , okay ?
[patient] okay .
[doctor] okay . do you have any questions ?
[patient] can i take all my pills at the same time ?
[doctor] yeah .
[patient] 'cause i've been trying to take them at different times of the day , 'cause i did n't know if it was bad to take them all at once or i should separate them . i do n't know .
[doctor] yeah . you can certainly take them , you know , all at the same time , as long , as yeah , they're all one scale . you can take them all at the same time . just set an alarm-
[patient] okay .
[doctor] . some time during the day to take them , okay ?
[patient] that might help me remember better .
[doctor] all right . that sounds good . all right , well , it's good to see you .
[patient] good seeing you too .
[doctor] hey , Sarah , finalize the note .

CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

Martha Collins is a 50-year-old female with a past medical history significant for congestive heart failure, depression, and hypertension who presents for her annual exam. It has been a year since I last saw the patient.

The patient has been traveling a lot recently since things have gotten a bit better. She reports that she got her COVID-19 vaccine so she feels safer about traveling. She has been doing a lot of hiking.

She reports that she is staying active. She has continued watching her diet and she is doing well with that. The patient states that she is avoiding salty foods that she likes to eat. She has continued utilizing her medications. The patient denies any chest pain, shortness of breath, or swelling in her legs.

Regarding her depression, she reports that she has been going to therapy every week for the past year. This has been really helpful for her. She denies suicidal or homicidal ideation.

The patient reports that she is still forgetting to take her blood pressure medication. She has noticed that when work gets more stressful, her blood pressure goes up. She reports that work has been going okay, but it has been a lot of long hours lately.

She endorses some nasal congestion from some of the fall allergies. She denies any other symptoms of nausea, vomiting, abdominal pain.

REVIEW OF SYSTEMS

• Ears, Nose, Mouth and Throat: Endorses nasal congestion from allergies.
• Cardiovascular: Denies chest pain or dyspnea on exertion.
• Respiratory: Denies shortness of breath.
• Gastrointestinal: Denies abdominal pain, nausea, or vomiting.
• Psychiatric: Endorses depression. Denies suicidal or homicidal ideations.

PHYSICAL EXAMINATION

• Cardiovascular: Grade 3/6 systolic ejection murmur.
1+ pitting edema of the bilateral lower extremities.

VITALS REVIEWED

• Blood Pressure: Elevated.

RESULTS

Echocardiogram demonstrates decreased ejection fraction of 45%. Mitral regurgitation is present.

Lipid panel: Elevated cholesterol.

ASSESSMENT AND PLAN

Martha Collins is a 50-year-old female with a past medical history significant for congestive heart failure, depression, and hypertension who presents for her annual exam.

Congestive heart failure.
• Medical Reasoning: She has been compliant with her medication and dietary modifications. Her previous year's echocardiogram demonstrated a reduced ejection fraction of 45%, as well as some mitral regurgitation. Her cholesterol levels were slightly elevated on her lipid panel from last year.
• Additional Testing: We will order a repeat echocardiogram. We will also repeat a lipid panel this year.
• Medical Treatment: She will continue with her current medications. We will increase her lisinopril to 40 mg daily and initiate Lasix 20 mg daily.
• Patient Education and Counseling: I encouraged her to continue with dietary modifications.

Depression.
• Medical Reasoning: She is doing well with weekly therapy.

Hypertension.
• Medical Reasoning: She has been compliant with dietary modifications but has been inconsistent with the use of her medication. She attributes elevations in her blood pressure to increased stress.
• Medical Treatment: We will increase her lisinopril to 40 mg daily as noted above.
• Patient Education and Counseling: I encouraged the patient to take her lisinopril as directed. I advised her to monitor her blood pressures at home for the next week and report them to me.

Healthcare maintenance.
• Medical Reasoning: The patient is due for her routine mammogram.
• Additional Testing: We will order a mammogram and have this scheduled for her.

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


[doctor] hi , andrew , how are you ?
[patient] hi . good to see you .
[doctor] it's good to see you as well . so i know that the nurse told you about dax . i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] okay ? so , andrew is a 62-year-old male with a past medical history significant for a kidney transplant , hypothyroidism , and arthritis , who presents today with complaints of joint pain . andrew , what's going on with your joint ? what happened ?
[patient] uh , so , over the the weekend , we've been moving boxes up and down our basements stairs , and by the end of the day my knees were just killing me .
[doctor] okay . is , is one knee worse than the other ?
[patient] equally painful .
[doctor] okay .
[patient] both of them .
[doctor] and did you , did you injure one of them ?
[patient] um , uh , i've had some knee problems in the past but i think it was just the repetition and the weight of the boxes .
[doctor] okay . all right . and , and what have you taken for the pain ?
[patient] a little tylenol . i iced them for a bit . nothing really seemed to help , though .
[doctor] okay . all right . um , and does it prevent you from doing , like , your activities of daily living , like walking and exercising and things like that ?
[patient] uh , saturday night it actually kept me up for a bit . they were pretty sore .
[doctor] mm-hmm . okay . and any other symptoms like fever or chills ?
[patient] no .
[doctor] joint pain ... i mean , like muscle aches ?
[patient] no .
[doctor] nausea , vomiting , diarrhea ?
[patient] no .
[doctor] anything like that ?
[patient] no .
[doctor] okay . all right . now , i know that you've had the kidney transplant a few years ago for some polycystic kidneys .
[patient] mm-hmm .
[doctor] um , how are you doing with that ? i know that you told dr. gutierrez-
[patient] mm .
[doctor] . a couple of weeks ago .
[patient] yes .
[doctor] everything's okay ?
[patient] so far , so good .
[doctor] all right . and you're taking your immunosuppressive medications ?
[patient] yes , i am .
[doctor] okay . all right . um , and did they have anything to say ? i have n't gotten any reports from them , so ...
[patient] no , n- nothing out of the ordinary , from what they reported .
[doctor] okay . all right . um , and in terms of your hyperthyroidism , how are you doing with the synthroid ? are you doing okay ?
[patient] uh , yes , i am .
[doctor] you're taking it regularly ?
[patient] on the clock , yes .
[doctor] yes . okay . and any fatigue ? weight gain ? anything like that that you've noticed ?
[patient] no , nothing out of the ordinary .
[doctor] okay . and just in general , you know , i know that we've kind of battled with your arthritis .
[patient] mm-hmm .
[doctor] you know , it's hard because you ca n't take certain medications 'cause of your kidney transplant .
[patient] sure .
[doctor] so other than your knees , any other joint pain or anything like that ?
[patient] every once in a while , my elbow , but nothing , nothing out of the ordinary .
[doctor] okay . all right . now i know the nurse did a review of systems sheet when you checked in . any other symptoms i might have missed ?
[patient] no .
[doctor] no headaches ?
[patient] no headaches .
[doctor] anything like that w- ... okay . all right . well , i wan na go ahead and do a quick physical exam , all right ? hey , Sarah , show me the vital signs . so here in the office , your vital signs look good . you do n't have a fever , which is good .
[patient] mm-hmm .
[doctor] your heart rate and your , uh , blood pressure look fine . i'm just gon na check some things out , and i'll let you know what i find , okay ?
[patient] perfect .
[doctor] all right . does that hurt ?
[patient] a little bit . that's tender .
[doctor] okay , so on physical examination , on your heart exam , i do appreciate a little two out of six systolic ejection murmur-
[patient] mm-hmm .
[doctor] . which we've heard in the past . okay , so that seems stable . on your knee exam , there is some edema and some erythema of your right knee , but your left knee looks fine , okay ? um , you do have some pain to palpation of the right knee and some decreased range of motion , um , on exam , okay ? so what does that mean ? so we'll go ahead and we'll see if we can take a look at some of these things . i know that they did an x-ray before you came in , okay ?
[patient] mm-hmm .
[doctor] so let's take a look at that .
[patient] sure .
[doctor] hey , Sarah , show me the right knee x-ray . so here's the r- here's your right knee x-ray . this basically shows that there's good bony alignment . there's no acute fracture , which is not surprising , based on the history .
[patient] mm-hmm .
[doctor] okay ? hey , Sarah , show me the labs . and here , looking at your lab results , you know , your white blood cell count is not elevated , which is good . you know , we get concerned about that in somebody who's immunocompromised .
[patient] mm-hmm .
[doctor] and it looks like your kidney function is also very good . so i'm , i'm very happy about that .
[patient] yeah .
[doctor] okay ? so i just wan na go over a little bit about my assessment and my plan for you .
[patient] mm-hmm .
[doctor] so for your knee pain , i think that this is an acute exacerbation of your arthritis , okay ? so i wan na go ahead and if ... and prescribe some ultram 50 milligrams every six hours as needed .
[patient] okay .
[doctor] okay ? i also wan na go ahead and just order an autoimmune panel , okay ? hey , Sarah , order an autoimmune panel . and you know , i , i want , i want you to just take it easy for right now , and if your symptoms continue , we'll talk about further imaging and possibly referral to physical therapy , okay ?
[patient] you got it .
[doctor] for your second problem , your hypothyroidism , i wan na go ahead and continue you on this ... on the synthroid , and i wan na go ahead and order some thyroid labs , okay ?
[patient] sure .
[doctor] hey , Sarah , order a thyroid panel . and then for your last problem , the arthritis , you know , we just kinda talked about that . you know , it's gon na be a struggle for you because again , you ca n't take some of those anti-inflammatory medications because of your kidney transplant , so ...
[patient] mm-hmm .
[doctor] you know , let's see how we do over the next couple weeks , and again , we'll refer you to physical therapy if we need to , okay ?
[patient] you got it .
[doctor] you have any questions ?
[patient] not at this point .
[doctor] okay . hey , Sarah , finalize the note .

CHIEF COMPLAINT

Joint pain.

HISTORY OF PRESENT ILLNESS

Andrew Perez is a 62-year-old male with a past medical history significant for a kidney transplant, hypothyroidism, and arthritis. He presents today with complaints of joint pain.

The patient reports that over the weekend, he was moving boxes up and down the basement stairs. By the end of the day, his knees were very painful. The pain is equal in the bilateral knees. He states that he has had some knee problems in the past, but he believes that it was due to the repetition and the weight of the boxes. He states that the pain does not prevent him from doing his activities of daily living. By the end of the day on Saturday, his knee soreness interrupted his sleep. The patient has taken Tylenol and iced his knees for a short period of time, but nothing really seemed to help.

The patient states that he had a kidney transplant a few years ago for some polycystic kidneys. He notes that he saw Dr. Gutierrez a couple of weeks ago, and everything was normal at that time. The patient continues to utilize his immunosuppressant medications.

Regarding his hypothyroidism, the patient states that he is doing well. He has continued to utilize Synthroid regularly.

In regards to his arthritis, the patient states that occasionally he has pain in his elbow, but nothing out of the ordinary.

He denies any other symptoms such as fever, chills, muscle aches, nausea, vomiting, diarrhea, fatigue, and weight loss.

REVIEW OF SYSTEMS

• Constitutional: Denies fevers, chills, or weight loss.
• Musculoskeletal: Denies muscle pain. Endorses joint pain in the bilateral knees.
• Neurological: Denies headaches.

PHYSICAL EXAMINATION

• Cardiovascular: 2/6 systolic ejection murmur, stable.
• Musculoskeletal: There is edema and erythema of the right knee with pain to palpation. Range of motion is decreased. Left knee exam is normal.

RESULTS

X-ray of the right knee is unremarkable. Good bony alignment. No acute fractures.

Labs: Within normal limits. White blood cell count is within normal limits. Kidney function is normal.

ASSESSMENT AND PLAN

Andrew Perez is a 62-year-old male with a past medical history significant for a kidney transplant, hypothyroidism, and arthritis. He presents today with complaints of joint pain.

Arthritis.
• Medical Reasoning: The patient reports increased joint pain in his bilateral knees over the past weekend. Given that his right knee x-ray was unremarkable, I believe this is an acute exacerbation of his arthritis.
• Additional Testing: We will order an autoimmune panel for further evaluation.
• Medical Treatment: Initiate Ultram 50 mg every 6 hours as needed.
• Patient Education and Counseling: I advised the patient to rest his knees. If his symptoms persist, we can consider further imaging and possibly a referral to physical therapy.

Hypothyroidism.
• Medical Reasoning: The patient is doing well on Synthroid and is asymptomatic at this time.
• Additional Testing: We will order a thyroid panel.
• Medical Treatment: Continue Synthroid.

Status post renal transplant.
• Medical Reasoning: He is doing well and has been compliant with his immunosuppressive medications. On recent labs, his white blood cell count was within a normal limits and his kidney function is stable.
• Medical Treatment: Continue current regimen.

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


[doctor] hi , john . how are you ?
[patient] hey . well , relatively speaking , okay . good to see you .
[doctor] good to see you as well . so i know the nurse told you about dax . i'm gon na tell dax a little bit about you .
[patient] okay .
[doctor] so john is a 61-year-old male with a past medical history significant for kidney stones , migraines and reflux , who presents with some back pain . so john , what's going on with your back ?
[patient] uh , i'm feeling a lot of the same pain that i had when i had kidney stones about two years ago , so i'm a little concerned .
[doctor] yeah . and so wh- what side of your back is it on ?
[patient] uh , honestly , it shifts . it started from the right side and it kinda moved over , and now i feel it in the left side of my back .
[doctor] okay . and , um , how many days has this been going on for ?
[patient] the last four days .
[doctor] okay . and is ... is the pain coming and going ?
[patient] um , at first it was coming and going , and then for about the last 48 hours , it's been a constant , and it's ... it's been pretty bad .
[doctor] okay . and what have you taken for the pain ?
[patient] tylenol , but it really does n't seem to help .
[doctor] yeah . okay . and do you have any blood in your urine ?
[patient] um , uh , it ... i think i do . it's kind of hard to detect , but it does look a little off-color .
[doctor] okay . all right . um , and have you had , uh , any other symptoms like nausea and vomiting ?
[patient] um , if i'm doing something i'm ... i'm , uh , like exerting myself , like climbing the three flights of stairs to my apartment or running to catch the bus , i feel a little dizzy and a little light headed , and i ... i still feel a little bit more pain in my abdomen .
[doctor] okay . all right . um , so let- let's talk a little bit about your ... your migraines . how are you doing with those ? i know we started you on the imitrex a couple months ago .
[patient] i've been pretty diligent about taking the meds . i ... i wan na make sure i stay on top of that , so i've been pretty good with that .
[doctor] okay , so no issues with the migraine ?
[patient] none whatsoever .
[doctor] okay . and how about your ... your acid reflux ? how are you doing with ... i know you were making some diet changes .
[patient] yeah , i've been pretty good with the diet , but with the pain i have been having, it has been easier to call and have something delivered. so i have been ordering a lot of take-out and fast food that can be delivered to my door so i don't have to go out and up and down the steps to get it myself. but other than that , it's been pretty good .
[doctor] okay . are you staying hydrated ?
[patient] yes .
[doctor] okay . all right . okay , well , let's go ahead and , uh , i know the nurse did a review of systems , you know , with you , and i know that you're endorsing some back pain and a little bit of dizziness , um , and some blood in your urine . any other symptoms ? you know , muscle aches , chest pain ... uh , body aches , anything like that ?
[patient] i have some body aches because i think i'm ... i'm favoring , um , my back when i'm walking because of the pain , like i kinda feel it in my muscles , but not out of the ordinary and not surprised 'cause i remember that from two years ago .
[doctor] okay . all right . well , let's go ahead and ... and look at your vital signs today . hey , Sarah ? show me the blood pressure . yeah , so your blood pressure's a little high today . that's probably because you're in some pain , um , but let ... let me just take a listen to your heart and lungs , and i'll let you know what i find , okay ?
[patient] sure .
[doctor] okay , so on ... on physical exam , you do have some , uh , cda tenderness on the right-hand side , meaning that you're tender when i ... when i pound on that .
[patient] mm-hmm .
[doctor] um , and your abdomen also feels a little tender . you have some tenderness of the palpation of the right lower quadrant , but other than that , your heart sounds nice and clear and your lungs are clear as well . so let's go ahead and take a look at some of your results , okay ?
[patient] sure .
[doctor] hey , Sarah ? show me the creatinine . so we ... we drew a creatinine when you came in here because i was concerned about the kidney stones . it ... it is uh ... it is up slightly , which might suggest that you have a little bit of a obstruction there of one-
[patient] mm-hmm .
[doctor] . of the stones . okay ? hey , Sarah . show me the abdominal x-rays . okay , and there might be a question of a ... uh , of a stone there lower down , uh , but we'll wait for the official read there . so the , uh , abdominal x-rays show a possible kidney stone , okay ?
[patient] okay .
[doctor] so let's talk a little bit about my assessment and plan for you . so , for your first problem , your back pain , i think you're having a recurrence of your kidney stones . so i wan na go ahead and order a ct scan without contrast of your abdomen and pelvis . okay ?
[patient] mm-hmm .
[doctor] and i'm also gon na order you some ultram 50 milligrams as needed every six hours for pain . does that sound okay ?
[patient] okay .
[doctor] hey , Sarah ? order ultram 50 milligrams every six hours as needed for pain . and i want you to push fluids and strain your urine . i know that you're familiar with that .
[patient] yes , i am .
[doctor] for your next problem , for your migraines , let's continue you on the imitrex . and for your final problem , uh , for your reflux , uh , we have you on the protonix 40 milligrams a day . do you need a refill of that ?
[patient] actually , i do need a refill .
[doctor] okay . hey , Sarah ? order a refill of protonix 40 milligrams daily . okay . so the nurse will be in soon , and she'll help you get the cat scan scheduled . and i'll be in touch with you in ... in a day or so .
[patient] perfect .
[doctor] if your symptoms worsen , just give me a call , okay ?
[patient] you got it .
[doctor] take care .
[patient] thank you .
[doctor] hey ... hey , Sarah ? finalize the note .

CHIEF COMPLAINT

Back pain.

HISTORY OF PRESENT ILLNESS

Mr. John Perry is a 61-year-old male with a past medical history significant for kidney stones, migraines, and gastroesophageal reflux, who presents with some back pain.

The patient reports that he is feeling a lot of the same pain that he had when he had kidney stones about 2 years ago, so he is a little concerned. The pain started from the right side and moved over and he feels it on the left side of his back. This has been going on for the last 4 days. Initially, the pain was intermittent, but over the last 48 hours it has been constant. He has taken Tylenol, but it does not seem to help. He thinks he has hematuria, but it is hard to detect but it does look a little off color. He endorses nausea and vomiting if he exerts himself or climbs the stairs to his apartment or runs to catch the bus. He also endorses dizziness and lightheadedness with pain in his abdomen.

Regarding his migraines, he has been diligent about taking the Imitrex. He denies issues with the migraines.

Regarding his gastroesophageal reflux, he reports that he has been doing well with his diet, but notes lately with his pain, he has been eating more fast food and takeout since these options come with delivery. He is staying hydrated. He is taking Protonix 40 mg daily as directed.

REVIEW OF SYSTEMS

• Gastrointestinal: Endorses abdominal pain. Endorses nausea and vomiting with exertion.
• Genitourinary: Endorses urine discoloration.
• Musculoskeletal: Endorses back pain. Endorses body aches.
• Neurological: Denies headaches. Endorses dizziness and lightheadedness.

PHYSICAL EXAMINATION

• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds.
• Gastrointestinal: Tender to palpation to the right lower quadrant. CVA tenderness on the right.

VITALS REVIEWED

• Blood Pressure: Elevated.

RESULTS

Creatinine level slightly elevated.
Abdominal x-ray demonstrates possible kidney stone.

ASSESSMENT AND PLAN

Mr. John Perry is a 61-year-old male with a past medical history significant for kidney stones, migraines, and gastroesophageal reflux, who presents with back pain.

Kidney stones.
• Medical Reasoning: He is experiencing pain in his back that is similar to his previous kidney stone pain. His recent abdominal x-ray demonstrates what appears to be a recurrent kidney stone.
• Additional Testing: I have ordered a CT scan of the abdomen and pelvis without contrast.
• Medical Treatment: We will start him on Ultram 50 mg as needed every 6 hours for pain.
• Patient Education and Counseling: I advised the patient to stay well hydrated and to strain his urine.

Migraines.
• Medical Reasoning: He has been compliant with Imitrex and is doing well at this time.
• Medical Treatment: Continue Imitrex.

Reflux.
• Medical Reasoning: This is typically well-controlled with dietary modifications.
• Medical Treatment: Continue with Protonix 40 mg daily. A refill was provided.

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


[doctor] hi , james , how are you ?
[patient] hey , good to see you .
[doctor] it's good to see you , too . so , i know the nurse told you about dax .
[patient] mm-hmm .
[doctor] i'd like to tell dax a little bit about you .
[patient] sure .
[doctor] james is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes who presents today with back pain .
[patient] mm-hmm .
[doctor] so , james , what happened to your back ?
[patient] uh , i was golfing and i hurt my back when i went for my backswing .
[doctor] okay . and did you feel a pop or a strain immediately or ?
[patient] i f- felt the pop , and i immediately had to hit the ground . i had to just try and do anything to loosen up my back .
[doctor] okay . and how long ago did this happen ?
[patient] this was saturday morning .
[doctor] okay . so , about four days ago ?
[patient] mm-hmm .
[doctor] okay . um , and what have you taken for the pain ?
[patient] uh , i took some tylenol . i took some ibuprofen .
[doctor] mm-hmm .
[patient] i tried ice . i tried heat , but nothing really worked .
[doctor] okay . and , h- how are you feeling now ? are you still in the same amount of pain ?
[patient] uh , by monday morning , it loosened up a little bit , but it's still pretty sore .
[doctor] okay . any other symptoms like leg weakness , pain in one leg , numbing or tingling ?
[patient] uh , i actually felt , um ... i had a struggle in my right foot like dropped foot . i had some struggling with my right leg . i felt that for a while , and it got a little bit better this morning but not much .
[doctor] okay . all right . um , so , are you ... how are you doing walking around ?
[patient] uh , uh , uh , i'm , i'm not going anywhere fast or doing anything strenuous but i can walk around a little bit .
[doctor] uh- .
[patient] not too fast .
[doctor] all right . okay . um , and any history with your back in the past ?
[patient] i actually had surgery about 10 years ago on my lower back .
[doctor] okay . all right . now , tell me a little bit about your , your heart failure . you know , i have n't seen you in a while .
[patient] mm-hmm .
[doctor] how are you doing with your diet ?
[patient] um , been pretty good t- taking my medications , watching my diet , trying to , uh , trying to exercise regularly , too .
[doctor] okay . so , you're avoiding the salty foods like we had talked about ?
[patient] yes .
[doctor] okay . and any weight gain or swelling in your legs recently ?
[patient] a little bit of weight gain over the summer but nothing , nothing too radical , nothing more than five pounds .
[doctor] okay . all right . and any problems laying flat while you go to bed ?
[patient] no .
[doctor] okay . uh , and lastly , what about your diabetes ? how are you doing with , with that diet ? i remember you have somewhat of a sweet tooth .
[patient] yeah .
[doctor] jelly beans ?
[patient] i love jelly beans , yeah , yeah . that's been a struggle , but i'm getting through it .
[doctor] okay . all right . um , and you're watching your blood sugars at home ?
[patient] mm-hmm . i monitor it regularly . not always, i can forget, , but i'm pretty good about my measuring it .
[doctor] okay . and you are still on your metformin ?
[patient] yes .
[doctor] okay . all right . all right . now , i know the nurse did a review of symptoms sheet when you checked in .
[patient] mm-hmm .
[doctor] i know that you were endorsing the back pain-
[patient] mm-hmm .
[doctor] . and maybe a little weakness in your right leg . um , any other symptoms ? i know we went through a lot .
[patient] no .
[doctor] okay . um , so , i wan na go ahead and move on to a physical exam , okay ?
[patient] mm-hmm .
[doctor] hey , Sarah , show me the vital signs . so , here in the office , you know , your vital signs look great . they look completely normal , which , which is really good .
[patient] good .
[doctor] okay ? so , i'm just gon na check you out , and i'm gon na let you know what i find , okay ?
[patient] mm-hmm .
[doctor] lean up . okay . all right . so , on your physical exam , everything seems fine .
[patient] good .
[doctor] on your heart exam , i do appreciate a 2 out of 6 systolic ejection murmur , which we've heard in the past-
[patient] mm-hmm .
[doctor] . so that's stable .
[patient] okay .
[doctor] on your back exam , you do have some pain to palpation of the lumbar 5 or lumbar spine-
[patient] mm-hmm .
[doctor] at the level of l5 .
[patient] okay .
[doctor] you have , you know , decreased range of motion with flexion and extension , and , um , you have a positive straight leg raise . uh , for your strength , you do have a 4 out of 5 on your right and 5 out of 5 on your left .
[doctor] so , what does that mean ? what does all that mean ? so , that basically means that , you know , i , i think that you probably , you know , have injured your , your back with a muscle strain , but we're gon na look at some of your results , okay ?
[patient] okay , sure .
[doctor] hey , Sarah , show me the back x-ray . so , in reviewing the results of your back x-ray , this is a normal x-ray of your lumbar spine . there's good boney alignment . i do n't see any abnormality there , which is not surprising based on the history , okay ?
[doctor] hey , Sarah , show me the diabetic labs . and this is just ... i just wanted to check your last , uh , diabetic labs that we did on you . uh , it looks like your hemoglobin a1c has been a little high at 8 . i'd like to see that a little bit lower around 7 , okay ?
[patient] okay .
[doctor] um , so , let's just talk a little bit about my assessment and my plan for you . um , so , for your first problem , i think you have an acute lumbar , um , strain .
[patient] mm-hmm .
[doctor] and i wan na go ahead and prescribe meloxicam 15 milligrams once a day , and i'd like to refer you to physical therapy to kind of strengthen that area . now , if you're still having symptoms , i wan na go ahead and , uh , order an mri-
[patient] mm-hmm .
[doctor] . just to make sure that you do n't have any disc herniation or anything like that , okay ?
[patient] that's fine .
[doctor] how does that sound ?
[patient] no problem .
[doctor] hey , Sarah , order meloxicam 15 milligrams once a day . for your next problem , your type 2 diabetes , i would like to increase your metformin to 1,000 milligrams twice daily-
[patient] mm-hmm .
[doctor] . and i wan na go ahead and order another hemoglobin a1c in a couple weeks , or , i'm sorry , a couple months .
[patient] okay .
[doctor] all right ? hey , Sarah , order a hemoglobin a1c . and for your congestive heart failure , uh , i think you're doing really well with it . um , you know , i wan na just continue you on your current medications , your lisinopril and your lasix . now , do you need a refill-
[patient] actually , i-
[doctor] of the lisinopril ?
[patient] actually , i do .
[doctor] okay . hey , Sarah , order a refill of lisinopril 20 milligrams once a day . and so , the nurse will come in . she's gon na help you get checked out . i wan na see you again in a couple weeks , okay ?
[patient] that's fine .
[doctor] um , any questions ?
[patient] not at this point .
[doctor] okay . hey , Sarah , finalize the note .

CHIEF COMPLAINT

Back pain.

HISTORY OF PRESENT ILLNESS

James Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain.

The patient states he was golfing and hurt his back. This happened approximately 4 days ago when he felt a pop in his back. The patient notes that he immediately hit the ground trying to loosen up his back. He reports taking some Tylenol, ibuprofen, and using ice and heat which did not relieve the pain. By Monday morning it loosened up a little bit, but it is still pretty sore. He had some right lower extremity weakness and some drop foot that he felt that for a while, and it got a little better this morning but not much. He had surgery about 10 years ago in his lower back.

Regarding his congestive heart failure, he has been watching his diet and trying to exercise regularly. He is avoiding the salty foods and has been compliant with medications. He has gained a little weight over the summer but nothing more than 5 pounds. He has no problems lying flat to go to bed.

Regarding his diabetes, he is watching his blood sugars at home, not always consistently. He is still on his metformin.

REVIEW OF SYSTEMS

• Constitutional: Denies weight loss. Endorses weight gain.
• Musculoskeletal: Endorses back pain. Endorses right leg weakness and drop foot.

PHYSICAL EXAMINATION

• Cardiovascular: Grade 2/6 systolic ejection murmur, stable.
• Musculoskeletal: Examination of his back reveals pain to palpation at L5. Decreased range of motion with flexion and extension. Positive straight leg raise. Strength is 4/5 on the right and 5/5 on the left.

Results:

X-ray lumbar spine, ordered and obtained in the office today, is unremarkable with good bony alignment.

Hemoglobin A1c is elevated at 8.

ASSESSMENT AND PLAN

James Allen is a 57-year-old male with a past medical history significant for congestive heart failure and type 2 diabetes, who presents today with back pain.

Acute lumbar strain.
• Medical Reasoning: The patient reports feeling a 'pop' and immediate pain while golfing approximately 4 days ago. He has tried Tylenol and ibuprofen without significant relief.
• Additional Testing: If he continues to have pain, we will obtain an MRI for further evaluation.
• Medical Treatment: Initiate meloxicam 15 mg once daily.
• Specialist Referrals: We will refer him to physical therapy to work on strengthening the area.

Diabetes type 2.
• Medical Reasoning: He has been compliant with metformin and dietary modifications, but his recent hemoglobin A1c was 8.
• Additional Testing: Repeat hemoglobin A1c in a couple of months.
• Medical Treatment: Increase metformin to 1000 mg twice daily.

Congestive heart failure.
• Medical Reasoning: He is doing well from this standpoint. He has been compliant with his medications, dietary modifications, and regular physical activity.
• Medical Treatment: Continue lisinopril 20 mg once daily and Lasix. Lisinopril was refilled today.

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

INSTRUCTIONS

The patient will follow-up in 2 weeks.


[doctor] hey , ms. hill . nice to see you .
[patient] hi , dr. james , good to see you .
[doctor] hey , Sarah , i'm seeing ms. hill . she's a 41-year-old female , and what brings you in today ?
[patient] um , i am having a lot of pain at the end of my right middle finger .
[doctor] what did you do ?
[patient] a little embarrassing . um , i got rear-ended , slow motor , uh , vehicle accident , and i got really angry with the person who hit me , so i went to flip him the bird , but i was a little too enthusiastic .
[patient] and i hit the ceiling of the car .
[doctor] okay . when did this happen ?
[patient] uh , it was saturday , so about four , five days ago .
[doctor] five days ago . what were you doing ? were you , like , stopped at a stoplight ? a stop sign ?
[patient] yes . so i was stopped at a four-way stop , and it was not my turn to go . there were other cars going , and the person behind me just was n't watching . i think they were texting and rear-ended me .
[doctor] how much damage to your car ?
[patient] uh , not too much . the , the trunk crumpled up a little bit .
[doctor] okay . and no other injuries ? just the finger ?
[patient] just the middle finger .
[doctor] so you would've escaped this accident without any injuries ?
[patient] yes . uh , i'm not proud .
[doctor] okay . um , so four days of right middle finger pain-
[patient] yes .
[doctor] . after a motor vehicle accident .
[patient] yes .
[doctor] all right . um , let's look at your x-ray . hey , Sarah , show me the last x-ray . so what i'm seeing here is on the tip of this middle finger , you actually have a fracture . so you have a distal phalanx fracture in the middle finger . very ...
[patient] great .
[doctor] very interesting . let me check it out . um , so does it hurt when i push right here ?
[patient] yes .
[doctor] and does that hurt ?
[patient] very much so .
[doctor] what about down here ?
[patient] no .
[doctor] okay . so generally , your exam is normal other than you've got tenderness over your distal phalanx of your right middle finger . um , so your diagnosis is distal phalanx fracture of the middle finger or the third finger . and i'm gon na put you on a little bit of pain medicine just to help , just , like , two days' worth . okay , so tramadol , 50 milligrams , every six hours as needed for pain . i'm gon na dispense eight of those .
[patient] okay .
[doctor] and then , um , i'm gon na put you in a finger splint and have you come back in two weeks to get a follow-up x-ray . any questions for me ?
[patient] yes . so i'm taking digoxin for afib . will the tramadol be okay with that ?
[doctor] it will be okay . so you have atrial fibrillation .
[patient] yes .
[doctor] you take digoxin .
all right . any other questions for me ?
[patient] no , that's it . thank you .
[doctor] you're welcome . hey , Sarah , go ahead and finalize the recording , and , uh , come with me . we'll get you checked out .

CC:

Right middle finger pain.

HPI:

Ms. Hill is a 41-year-old female who presents today for an evaluation of right middle finger pain after she was rear-ended in a motor vehicle accident. She has no other injuries.

CURRENT MEDICATIONS:

Digoxin

PAST MEDICAL HISTORY:

Atrial Fibrillation

EXAM

Examination of the right middle finger shows tenderness over the distal phalanx.

RESULTS

X-rays of the right middle finger, 3 views obtained on today's visit shows a comminuted distal phalanx fracture.

IMPRESSION

Right middle finger distal phalanx fracture.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I recommend a prescription for Tramadol 50 mg every 6 hours as needed for pain, dispense 8. She is provided a finger splint and will return in 2 weeks for a follow-up x-ray. All questions were answered.


[doctor] hi , anna . how are you ?
[patient] i'm doing okay . how are you ?
[doctor] i'm doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you .
[patient] all right .
[doctor] so , anna is a 44-year-old female with a past medical history significant for arthritis , gout , and reflux , who presents today for follow up of her chronic problems .
[doctor] so , anna , it's been probably about six months since i've seen you . how are you doing ?
[patient] i'm doing okay . um , my arthritis is starting to get better . um , i've been trying to move my body , doing pilates , lifting weights , um , and that's , kind of , helped me build up some muscle , so the joint pain is , has been going away .
[doctor] okay . yeah . i know you were having , you know , some problems with your right knee , uh , and we sent you for physical therapy . so , so that's going well ?
[patient] yeah . the physical therapy's gone really well . i've built up my strength back and it's been really great .
[doctor] okay . so you feel like you're able to walk a little bit further now ?
[patient] yup . i'm walking about a mile , a mile and a half a day .
[doctor] okay . great . that's good . i'm glad to hear that . okay .
[doctor] and then , in terms of your gout , um , how are you doing with that ? i know you had an episode of gout of your , your right first big toe , um , about two months ago . how are you doing with that ?
[patient] i'm doing , doing well . the medication helped it , you know , go down and go away . hopefully , , it does n't come back .
[doctor] okay . and are you taking the allopurinol that i prescribed ?
[patient] yes .
[doctor] okay . and no issues with that ?
[patient] nope .
[doctor] okay . great . um , no further flare ups ?
[patient] no .
[doctor] okay . great . all right .
[doctor] and then , you know , how about your reflux ? we had placed you on , um , omeprazole , you know , to help with some of those symptoms and i know that you were gon na do some dietary modifications . how are you doing with that ?
[patient] so , i started to make some dietary modifications . unfortunately , i have n't cut the stone out quite yet . um , i've still been having some episodes and , and throwing up in the mornings , um , things like that .
[doctor] you're throwing up in the morning ?
[patient] yup .
[doctor] like , just , like , reflux into your throat or are you actually vomiting ?
[patient] um , actually vomiting .
[doctor] okay . that's a problem .
[patient] yup .
[doctor] all right . well , um , let's talk about any other symptoms that you might have . have you had any abdominal pain ? um , diarrhea ? um , do you feel like your belly's bigger than usual ?
[patient] um , the , the first and the last . so , i've been having some abdominal pain and then i feel like i'm bloated all the time .
[doctor] okay . and when was your last bowel movement ?
[patient] uh , probably two days ago .
[doctor] okay . was it normal ?
[patient] yes .
[doctor] okay . any blood ?
[patient] no .
[doctor] okay . all right . and any weight loss ? anything like that ?
[patient] no , not that i've noticed .
[doctor] okay . and any fever or chills ?
[patient] no .
[doctor] okay . all right . uh , well , sounds like we just did the review of systems with you . it sounds like you're endorsing this , you know , nausea , vomiting , abdominal distension . um , any other symptoms ?
[patient] no .
[doctor] no ? okay . all right . well , i wan na go ahead and do a quick physical exam . okay ?
[doctor] hey , Sarah , show me the vital signs . all right . well , your , your vital signs here look quite good . all right . so , i'm , i'm reassured by that . i'm just gon na check out your heart and lungs and your belly and , and l- let you know what i find , okay ?
[patient] okay .
[doctor] all right . so , on physical examination , you know , everything looks good . your heart sounds good . your lungs sound good . you know , on your abdominal exam , you do have some pain to your right upper quadrant when i press on it , um , and there's no rebound or guarding and there's no peritoneal signs and your right knee does show a little bit of , uh , an effusion there and there's , uh , some slight pain to palpation and some decreased range of motion .
[doctor] so what does that mean , you know ? that means that you have some findings on your belly exam that concern me about your gall bladder , okay ? so , we'll have to look into that and then , um , your right knee looks a little swollen , but you know , we know you have some arthritis there , okay ?
[patient] okay .
[doctor] let's take a look at some of your results . hey , Sarah , show me the autoimmune panel . hey , Sarah , show me the autoimmune labs .
[doctor] okay . so looking at your autoimmune panel here , you know , we sent that because , you know , you're young and you have , you know , arthritis and gout and that type of thing and everything seemed to be fine .
[patient] okay .
[doctor] hey , Sarah , show me the right knee x-ray .
[doctor] so , looking here at your right knee x-ray , you know , there's no fracture or anything , but you know , it does show that you do have that residual arthritis there , um , that we're , you know , we're working on improving so that we do n't have to do some type of surgery or intervention , okay ?
[patient] okay .
[doctor] so let's talk a little bit about my assessment and plan for you , okay ? so , for your first problem , um , your reflux and your nausea and vomiting , uh , i wan na go ahead and get a right upper quadrant ultrasound to rule out any gallstones , okay ? um , and then i'm gon na check some labs on you . okay ?
[patient] okay .
[doctor] i want you to continue on the omeprazole , 40 milligrams , once a day and continue with those dietary modifications .
[doctor] um , for your second problem , your gout , um , you know , everything seems controlled right now . let's continue you on the allopurinol , 100 milligrams , once a day . um , do you need a refill of that ?
[patient] yes , i do actually .
[doctor] hey , Sarah , order allopurinol , 100 milligrams , once daily .
[doctor] and then from your last problem , your arthritis , i'm very pleased with how your right knee is doing and i want you to continue pilates and using the knee and let me know if you have any issues and we can , and we can talk about further imaging or intervention at that time , okay ?
[patient] okay .
[doctor] any questions ?
[patient] uh , no . that's it .
[doctor] okay . great . hey , Sarah , finalize the note .

CHIEF COMPLAINT

Follow-up of chronic problems.

HISTORY OF PRESENT ILLNESS

Anna Mitchell is a 44-year-old female with a past medical history significant for arthritis, gout, and reflux, who presents today for follow-up of her chronic problems. It has been about 6 months since I last saw the patient.

The patient reports her arthritis is starting to get better. She has been trying to move her body with pilates and lifting weights. This has helped build up some muscles and her joint pain has reduced. The patient has also continued to attend physical therapy, which she feels has been beneficial.

Ms. Mitchell had an episode of gout of her right first big toe about 2 months ago. She states she is doing well on the allopurinol 100 mg once daily and has had no further flare ups.

Regarding her acid reflux, she was placed on omeprazole 40 mg once a day to help with some of the symptoms she was having. She started to make some dietary modifications, but she still needs to make more progress. She reports episodes of vomiting in the morning. The patient also has abdominal pain and bloating. Her last bowel movement was 2 days ago, and it was normal. She denies blood in her stool.

The patient denies unexplained weight gain or loss, fevers, chills.

REVIEW OF SYSTEMS

• Constitutional: Denies fevers, chills, or weight loss.
• Gastrointestinal: Denies hematochezia, melena. Endorses vomiting, abdominal pain, and bloating.
• Musculoskeletal: Endorses joint pain.

PHYSICAL EXAMINATION

• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: No murmurs, gallops, or rubs. No extra heart sounds.
• Gastrointestinal: Pain to palpation of the right upper quadrant. No rebound or guarding. No peritoneal signs.
• Musculoskeletal: Right knee shows a little effusion. Slight pain to palpation. Some decreased range of motion.

RESULTS

Autoimmune panel is within normal limits.

X-ray of the right knee demonstrates residual arthritis. No fractures noted.

ASSESSMENT AND PLAN

Anna Mitchell is a 44-year-old female with a past medical history significant for arthritis, gout, and reflux, who presents today for follow-up of her chronic problems.

Acid reflux with nausea and vomiting.
• Medical Reasoning: She reports episodes of vomiting in the morning, as well as abdominal pain and bloating. She has been compliant with omeprazole and has made a few dietary modifications.
• Additional Testing: We will order an ultrasound of her right upper quadrant, as well as additional labs, to rule out biliary etiology.
• Medical Treatment: Continue omeprazole 40 mg once daily.
• Patient Education and Counseling: I encouraged her to continue with dietary modifications.

Gout.
• Medical Reasoning: Her flares are well controlled on allopurinol.
• Medical Treatment: Continue allopurinol 100 mg once daily. This was refilled today.

Arthritis.
• Medical Reasoning: She is doing well and has remained active since her last visit. Physical therapy has also been beneficial for her. Her right knee x-ray demonstrated residual arthritis but was otherwise normal.
• Patient Education and Counseling: I advised her to continue pilates and using the knee. She will contact me if she has any issues and we can consider further imaging or intervention at that time.

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


[doctor] and why is she here ? annual exam . okay . all right . hi , sarah . how are you ?
[patient] good . how are you ?
[doctor] i'm good . are you ready to get started ?
[patient] yes , i am .
[doctor] okay . so sarah is a 27-year-old female here for her annual visit . so , sarah , how have you been since the last time i saw you ?
[patient] i've been doing better . um , i've been struggling with my depression , um , a bit more just because we've been trapped really inside and remotely over the past year , so i've been struggling , um , off and on with that .
[doctor] okay . uh , and from looking at the notes , it looks like we've had you on , uh , prozac 20 milligrams a day .
[patient] yes .
[doctor] are , are you taking that ?
[patient] i am taking it . i think it's just a lot has been weighing on me lately .
[doctor] okay . um , and do you feel like you need an increase in your dose , or do you ... what are you thinking ? do you think that you just need to deal with some stress or you wan na try a , a different , uh , medication or ...
[patient] i think the , the medication has helped me in the past , and maybe just increasing the dose might help me through this patch .
[doctor] okay . all right . and , and what else has been going on with you ? i know that you've had this chronic back pain that we've been dealing with . how's that , how's that going ?
[patient] uh , i've been managing it . it's still , um , here nor there . just , just keeps , um , it really bothers me when i sit for long periods of time at , at my desk at work . so i have ... it helps when i get up and move , but it gets really stiff and it hurts when i sit down for long periods of time .
[doctor] okay , and do you get any numbing or tingling down your legs or any pain down leg versus the other ?
[patient] a little bit of numbing , but nothing tingling or hurting down my legs .
[doctor] okay , and does the , um , do those symptoms improve when you stand up or change position ?
[patient] yeah , it does .
[doctor] okay . all right . and any weakness in , in your legs ?
[patient] no , no weakness , just , just the weird numbing . like , it's , like , almost like it's falling asleep on me .
[doctor] okay . and are you able to , um , do your activities of daily living ? do you exercise , go to the store , that type of thing ?
[patient] yeah , i am . it bothers me when i'm on my feet for too long and sitting too long , just the extremes of each end .
[doctor] okay . and i know that you've had a coronary artery bypass grafting at the young age of 27 , so how's that going ?
[patient] yeah , i had con- i had a congenital ... you know , i had a congenital artery when i was a baby , so , um , they had to do a cabg on me , um , fairly young in life , but i've been ... my heart's been doing , doing well , and arteries have been looking good .
[doctor] okay . all right , well , let's go ahead and do a quick physical exam . um , so looking at you , you do n't appear in any distress . um , your neck , there's no thyroid enlargement . uh , your heart i hear a three out of six , systolic ejection murmur , uh , that's stable . your lungs otherwise sound clear . your abdomen is soft , and you do have some pain to palpation of your lumbar spine . uh , and you've had decreased flexion of your back . uh , your lower extremity strength is good , and there's no edema . so let's go ahead and look at some of your results . hey , Sarah , show me the ecg . okay , so that looks basically unchanged from last year , which is really good . hey , Sarah , show me the lumbar spine x-ray . hey , Sarah , show me the back x-ray . great . so this looks good . that's also stable from last year . okay . so let's go ahead and , you know , my , my plan for you at this time , you know , from a chronic back pain standpoint , if you need , um , you know , some more physical therapy , and i can refer you to physical therapy to help with those symptoms that are kind of lingering .
[patient] mm-hmm .
[doctor] um , and we can always give you some pain medication if you , if you get some pain periodically with activity . how do you feel about that ? do you need some pain medication ?
[patient] no , i think physical therapy is the right way to , way to start out on this .
[doctor] okay . hey , Sarah , order physical therapy referral . and then in terms of your depression , we talked about increasing your prozac , so we'll increase it from 20 milligrams to 40 milligrams . it's just one tablet once a day .
[patient] okay .
[doctor] um , and i'll send those to your pharmacy . does that sound okay ?
[patient] that sounds great .
[doctor] hey , Sarah , order prozac , 40 milligrams , once a day . and then in terms of your ... the heart bypass that you've had ... let's go ahead and just order another echocardiogram for you , and i wan na continue you on the aspirin for now , okay ?
[patient] okay .
[doctor] hey , Sarah , order an echocardiogram . hey , Sarah , order aspirin 81 milligrams daily . okay , so the nurse will come in . she'll help you schedule those things , and we'll go from there , okay ?
[patient] okay .
[doctor] all right , take care .
[patient] thank you .
[doctor] hey , Sarah , finalize the note .

CHIEF COMPLAINT

Annual visit.

HISTORY OF PRESENT ILLNESS

The patient is a 27-year-old female who presents for her annual visit. The patient reports that she has been doing better since her last visit. She reports that she has been struggling with her depression off and on for the past year. The patient notes that it might be due been trapped inside and remotely over the past year. She reports that she is taking Prozac 20 mg, but she believes that it has been weighing on her lately. She notes that an increase in her Prozac dose might be beneficial for her at this time.

The patient reports that she has had chronic back pain that she has been managing. She reports that she experiences stiffness and pain when she sits or stands for long periods of time at her desk at work. She reports that it helps when she gets up and moves. She reports that she has a little bit of numbness down her legs, but no tingling or pain down her legs. She reports that the symptoms improve when she stands up or changes positions. She denies any weakness in her legs.

She reports that she has had a coronary artery bypass grafting. She reports that she had a congenital artery when she was a baby and they had to do a CABG on her fairly young age. She reports that her heart has been doing well and her arteries have been looking good.

REVIEW OF SYSTEMS

• Musculoskeletal: Endorses back pain.
• Neurological: Endorses numbness in legs.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Constitutional: in no apparent distress.
• Neck: Supple without thyromegaly.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: 3/6 systolic ejection murmur, stable.
• Musculoskeletal: Pain to palpation of the lumbar spine. Decreased flexion of back. Lower extremity strength is good.

RESULTS

Echocardiogram appears unchanged in comparison to last year.

X-rays of the lumbar spine stable in comparison to last year.

ASSESSMENT

The patient is a 27-year-old female who presents today for an annual followup of chronic conditions.

Chronic back pain.
• Medical Reasoning: She is experiencing worsened pain with sitting for extended periods of time.
• Medical Treatment: Physical therapy referral ordered. Patient would like to defer pain medication at this time.

Depression
• Medical Reasoning: The patient was previously doing well on Prozac 20 mg once daily but feels as though she needs a higher dose at this time.
• Medical Treatment: Increase Prozac to 40 mg once daily. Prescription submitted.

History of coronary artery bypass graft.
• Medical Reasoning: She is doing well at this time. We will continue to monitor this.
• Medical Treatment: Echocardiogram ordered. Continue aspirin 81 mg daily.