TaskB-ValidationSet.csv

dataset,encounter_id,dialogue,note
virtassist,D2N068,"[doctor] hi , brian . how are you ?
[patient] hi , good to see you .
[doctor] it's good to see you too . so , i know the nurse told you a little bit about dax .
[patient] mm-hmm .
[doctor] i'd like to tell dax about you , okay ?
[patient] sure .
[doctor] so , brian is a 58 year old male with a past medical history significant for congestive heart failure and hypertension , who presents today for follow-up of his chronic problems . so , brian , it's been a little while i've seen you .
[patient] mm-hmm .
[doctor] whats , what's going on ?
[patient] i , i just feel out of sorts lately . i do n't know if it's the change in the seasons or if we're just doing a lot of projects around the house and , and some , some construction on our own . i'm just feeling out of it . lack of , uh , energy . i'm just so tired and fatigued , and i feel kinda ... i feel lightheaded every once in a while .
[doctor] okay . all right . um , how long has that been going on for ?
[patient] uh , probably since labor day , so about five weeks or so .
[doctor] okay . and , have you noticed any , like , symptoms of weight gain , like , like swollen legs , or , you know , your belly feels bloated and things like that ?
[patient] i feel , i feel bloated every once in a while .
[doctor] okay . all right . um , and , are you taking your , your medications ?
[patient] uh , yes , i am .
[doctor] okay . and , how about your diet ? are you watching your diet ?
[patient] uh , it's been a little bit of a struggle . we began construction on our kitchen over labor day weekend , and it was ... hard to cook or prepare meals so we ate out a lot, and not always the best food out. it , it , it kind of reeked havoc , uh , so it's been maybe off a little bit .
[doctor] okay . all right . and , how about , you know , other symptoms , like , have you had a fever or chills ?
[patient] no .
[doctor] okay , and any problems breathing ? do you feel short of breath ?
[patient] uh , just when i'm doing doing the projects . again , not even lifting anything really heavy , it's just that if i'm ex- exerting any energy , i , i kinda feel it at that point .
[doctor] okay . do you have any chest pain ?
[patient] slight cramps . that seems to go away after about , maybe about an hour or so after i first feel it .
[doctor] okay , and how about a cough ?
[patient] a , a slight cough , and again , i'm not sure if it's just the change of seasons and i'm getting a cold .
[doctor] mm-hmm . okay . all right . well , you know , for the most part , how , you know , before all of this-
[patient] mm-hmm .
[doctor] . how were you doing with your heart failure ? i know that we've kinda talked about you being able to watch your healthy food intake and that's been kind of a struggle in the past .
[patient] i , i , i've actually been pretty good about that ever since . the , the , the last year , it's been a little chaotic , but i wanted to make sure i stayed on top of that .
[doctor] okay . all right . are you excited for halloween ?
[patient] uh , ca n't wait .
[doctor] okay .
[patient] our home renovations should be complete by then
[doctor] all right , yeah , right .
[patient] yeah .
[doctor] and , so , lastly , for your high blood pressure , how are you doing with that ? have , are , did you buy the blood pressure cuff like i asked ?
[patient] yeah , i , i did , and we do mon- , i , i monitor it regularly . my wife makes sure i stay on top of that , but it's been pretty good .
[doctor] okay . all right . well , i know you did the review of systems sheet when you checked in , and you were endorsing this fatigue-
[patient] mm-hmm .
[doctor] . and a little dizziness and we just talked a lot about a lot of other symptoms .
[patient] mm-hmm .
[doctor] any other symptoms i might be missing ? nausea or vomiting , diarrhea ?
[patient] no .
[doctor] anything like that ?
[patient] no .
[doctor] okay . all right . well , i just want to go ahead and do a quick physical exam .
[patient] mm-hmm .
[doctor] hey , dragon ? show me the vital signs . so , looking at your vital signs here in the office , everything looks good . you know , your blood pressure and your heart rate and your oxygenation all look really good .
[patient] mm-hmm .
[doctor] so , i'm gon na just take a listen to a few things and check some things out , and i'll let you know what i find , okay ?
[patient] perfect .
[doctor] okay . so , on your physical examination , you know , i do appreciate some jugular venous distention to-
[patient] mm-hmm .
[doctor] to about eight centimeters . on your heart exam , i do appreciate a three out of six systolic ejection murmur , which we've heard in the past . and , on your lung exam , i do appreciate some fine crackles at the bases bilaterally , and your lower extremities have , you know , 1+ pitting edema . so , what does all that mean ? that means i think you're retaining a little bit of fluid .
[patient] mm-hmm .
[doctor] okay ? i wan na just go ahead and look at some of your results , okay ?
[patient] sure .
[doctor] hey , dragon ? show me the chest x-ray . so , looking here at the results of your chest x-ray , it does look like you have a little bit of fluid in your lungs there , and that can be just from , um , your heart failure , okay ? hey , dragon ? show me the echocardiogram . so , this is the echocardiogram that we did about four months ago , and this shows that the pumping function of your heart is a little bit reduced at 45 % , and it also shows that leaky valve , the mitral regurgitation that , that you have , okay ? um , so , let me just go over and talk about , a little bit , my assessment and my plan for you .
[patient] mm-hmm .
[doctor] okay ? so , for your first problem , your congestive heart failure , i think you're retaining fluid , and i wan na go ahead and increase your lasix to 80 mg once a day .
[patient] mm-hmm .
[doctor] i want you to weigh yourself every day . i want you to call me if you're gaining more weight .
[patient] mm-hmm .
[doctor] and , i certainly want you to call me if you have any other symptoms of shortness of breath , and i wan na go ahead and order another echocardiogram , okay ?
[patient] sure .
[doctor] hey , dragon ? order an echocardiogram .
lastly , for your high blood pressure , it looks like you're managing it well at this time , okay ? so , i wan na go ahead and continue with the lisinopril 20 mg a day . i want you to continue to record your blood pressures at home , and report them to me in the patient portal if you see they're getting elevated , okay ?
[patient] mm-hmm .
[doctor] does that sound like a plan ?
[patient] that sounds fine .
[doctor] okay . um , i'm gon na be in touch with you after we get your test results , and we'll go from there , okay ?
[patient] sure .
[doctor] all right . hey , dragon , finalize the note .","CHIEF COMPLAINT

Follow-up of chronic problems.

HISTORY OF PRESENT ILLNESS

Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow-up of his chronic problems.

The patient states he has been feeling out of sorts lately. He is not sure if it is due to the change in the seasons or due to performing lots of projects and some construction on his home. He reports fatigue and lightheadedness. This has been going on for about 5 weeks. While exerting energy, he has experienced some shortness of breath and chest cramps. The patient also notes a slight cough, but he is not sure if it is just the change in seasons.

He feels bloated every once in a while. His diet has been a little bit of a struggle. They had construction on their kitchen begin over Labor Day weekend, and have been eating less healthy food as a result.

Regarding his heart failure, he has been pretty good with his salt intake. He has been pretty good about his diet since the last year and is staying on top of that as much as possible. The patient has continued to utilize Lasix daily.

For his hypertension, this has been well controlled with lisinopril 20 mg a day. He has continued to monitor his blood pressure regularly.

The patient did the review of systems sheet when he checked in. He denies weight gain, swelling in the lower extremities, fevers, chills, dizziness, nausea, vomiting, and diarrhea.

REVIEW OF SYSTEMS

• Constitutional: Endorses fatigue. Denies fevers, chills, or weight loss.
• Cardiovascular: Endorses chest pain or dyspnea on exertion.
• Respiratory: Endorses cough and shortness of breath.
• Gastrointestinal: Endorses bloating.

PHYSICAL EXAMINATION

• Neck: JVD 8 cm.
• Respiratory: Rales bilateral bases.
• Cardiovascular: 3/6 systolic ejection murmur.
• Musculoskeletal: 1+ pitting edema bilateral lower extremities.

RESULTS

X-ray of the chest demonstrates a mild amount of fluid in the lungs.

Echocardiogram demonstrates decreased ejection fraction of 45% and mild mitral regurgitation.

ASSESSMENT AND PLAN

Brian White is a 58-year-old male with a past medical history significant for congestive heart failure and hypertension, who presents today for follow up of his chronic problems.

Congestive heart failure.
• Medical Reasoning: The patient reports increased fatigue, dizziness, and chest discomfort on exertion. He also exhibits some jugular venous distention, lung base crackles, and lower extremity edema on exam today. He has been compliant with his current medications but admits to dietary indiscretion lately. His recent echocardiogram demonstrated a reduced ejection fraction of 45%, as well as mitral regurgitation.
• Additional Testing: We will order a repeat echocardiogram.
• Medical Treatment: Increase Lasix to 80 mg daily.
• Patient Education and Counseling: I advised the patient to monitor and record his daily weight and report those to me via the patient portal. He will contact me should he continue to experience any dyspnea.

Hypertension.
• Medical Reasoning: This is well controlled based on home monitoring.
• Medical Treatment: Continue lisinopril 20 mg daily.
• Patient Education and Counseling: I advised him to monitor and record his blood pressures at home and report these to me via the patient portal.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan."
virtassist,D2N069,"[doctor] hi , ms. thompson . i'm dr. moore . how are you ?
[patient] hi , dr. moore .
[doctor] hi .
[patient] i'm doing okay except for my knee .
[doctor] all right , hey , dragon , ms. thompson is a 43 year old female here for right knee pain . so tell me what happened with your knee ?
[patient] well , i was , um , trying to change a light bulb , and i was up on a ladder and i kinda had a little bit of a stumble and kinda twisted my knee as i was trying to catch my fall .
[doctor] okay . and did you injure yourself any place else ?
[patient] no , no . it just seems to be the knee .
[doctor] all right . and when did this happen ?
[patient] it was yesterday .
[doctor] all right . and , uh , where does it hurt mostly ?
[patient] it hurts like in , in , in the inside of my knee .
[doctor] okay .
[patient] right here .
[doctor] all right . and anything make it better or worse ?
[patient] i have been putting ice on it , uh , and i've been taking ibuprofen , but it does n't seem to help much .
[doctor] okay . so it sounds like you fell a couple days ago , and you've hurt something inside of your right knee .
[patient] mm-hmm .
[doctor] and you've been taking a little bit of ice , uh , putting some ice on it , and has n't really helped and some ibuprofen . is that right ?
[patient] that's right . yeah .
[doctor] okay , let's review your past history for a second . it looks like , uh , do you have any other past medical history ?
[patient] uh , afib .
[doctor] okay , and are you taking any medications for that ?
[patient] yeah , i am . um , begins with a d.
[doctor] uh , digoxin ?
[patient] that's it . yeah , that's it .
[doctor] okay , all right . how about any surgeries in the past ?
[patient] i have had a nose job .
[doctor] all right . um , let's do your exam , okay ? so is it tender ... where is it mostly tender right now ?
[patient] right on the inside of my knee . right here .
[doctor] all right , so if i bend your knee forward , does that seem to hurt ?
[patient] yes , that hurts .
[doctor] all right , how about if i twist it a little bit that way .
[patient] that hurts a lot .
[doctor] okay , okay . and how about down here ? do you feel me touch you down here ?
[patient] yes .
[doctor] all right . any other pain down here in your calves ?
[patient] no .
[doctor] no , okay . so on exam you do have some tenderness over the medial portion of your knee over the medial meniscus area . uh , there is no , uh , there is a little bit of tenderness when i flex your , uh , when i , uh , uh , do some valgus stressing on your , on your leg . um , you have normal sensation . so let's take a look at your x-rays .
[patient] okay .
[doctor] okay . hey dragon , show me the x-rays . so looking at the x-ray , um , of your left knee , uh , it appears to be there's no fractures there right now . i do n't see any , uh , there's a little bit of , uh , fluid , uh , but there is no , uh , there's no , um , fracture or there's no dislocation . everything else seems to be lined up properly , okay ?
[patient] okay .
[doctor] so in summary after my exam , uh , looking at your knee , uh , on the x-ray and your exam , you have some tenderness over the medial meniscus , so i think you have probably an acute medial meniscus sprain right now or strain . uh , at this point , my recommendation would be to put you in a knee brace , uh , and we'll go ahead and have you use some crutches temporarily for the next couple days . we'll have you come back in about a week and see how you're doing , and if it's not better , we'll get an mri at that time .
[patient] okay .
[doctor] i'm going to recommend we give you some motrin , 800 milligrams . uh , you can take it about every six hours , uh , with food . uh , and we'll give you about a two week supply .
[patient] okay .
[doctor] okay . uh , do you have any questions ?
[patient] no , i think i'm good .
[doctor] all right . hey , dragon , order the medications and procedures discussed , and finalize the report . okay , come with me and we'll get you checked out .","CC:

Right knee pain.

HPI:

Ms. Thompson is a 43-year-old female who presents today for an evaluation of right knee pain. She states she was trying to change a lightbulb on a ladder, and she twisted her knee when she stumbled and caught herself from falling yesterday. She has been applying ice and taking Ibuprofen without relief.

CURRENT MEDICATIONS:

Ibuprofen, digoxin.

PAST MEDICAL HISTORY:

Atrial fibrillation.

PAST SURGICAL HISTORY:

Rhinoplasty.

EXAM

Examination of the right knee shows pain with flexion. Tenderness over the medial joint line. No pain in the calf. Pain with valgus stress. Sensation is intact.

RESULTS

X-rays of the right knee show no obvious signs of acute fracture or dislocation. Mild effusion is noted.

IMPRESSION

Right knee acute medial meniscus sprain.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a knee brace. She will take Motrin 800 mg, every 6 hours with food, for two weeks. She will use crutches for the next couple of days. She will follow up with me in 1 week for a repeat evaluation. If she is not better at that time, we will obtain an MRI. All questions were answered.
"
virtassist,D2N070,"[doctor] hi logan . how are you ?
[patient] hey , good to see you .
[doctor] it's good to see you as well .
[doctor] 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] so logan is a 58 year old male , with a past medical history significant for diabetes type 2 , hypertension , osteoarthritis , who presents today with some back pain .
[patient] mm-hmm .
[doctor] so logan , what happened to your back ?
[patient] uh , we were helping my daughter with some heavy equipment and lifted some boxes a little too quickly , and they were a little too heavy .
[doctor] okay ... and did you strain your back , did something-
[patient] i thought i heard a pop when i moved and i had to lie down for about an hour before it actually relieved the pain . and then it's been a little stiff ever since . and this was- what , so today's tuesday . this was saturday morning .
[doctor] okay , all right .
[doctor] and is it your lower back , your upper back ?
[patient] my lower back .
[doctor] your lower back , okay . and what- what have you taken for the pain ?
[patient] i took some tylenol , i took some ibuprofen , i used a little bit of icy heat on the spot but it really did n't seem to help .
[doctor] okay . and um ... do you have any numbing or tingling in your legs ?
[patient] uh ... i felt some tingling in my toes on my right foot until about sunday afternoon . and then that seemed to go away .
[doctor] okay , and is there a position that you feel better in ?
[patient] uh ... it's really tough to find a comfortable spot sleeping at night . i would- i tend to lie on my right side and that seemed to help a little bit ?
[doctor] okay , all right .
[doctor] well , um ... so how are you doing otherwise ? i know that , you know , we have some issues to talk-
[patient] mm-hmm .
[doctor] . about today . were you able to take any vacations over the summer ?
[patient] um ... some long weekends , which was great . just kind of- trying to mix it up through the summer . so lots of three day weekends .
[doctor] okay , well i'm glad to hear that .
[doctor] um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ...
[patient] yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar .
[patient] and uh ... i-i think i need to go clean for a couple of weeks . but other than that , it was been- it's been pretty good eating .
[doctor] okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ?
[patient] i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , but it's been pretty good and-and under control for the most part .
[doctor] okay , and you're you're taking your medication ?
[patient] yes , i am .
[doctor] okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ?
[patient] uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . not great , but it's been okay .
[doctor] okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain .
[doctor] have you had any other symptoms , chest pain , nausea or vomiting-
[patient] no .
[doctor] . fever , chills ?
[patient] no . no none whatsoever .
[doctor] no . okay . all right , well let me go ahead , i want to do a quick physical exam .
[patient] mm-hmm .
[doctor] hey dragon ? show me the blood pressure .
[doctor] so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your-
[patient] mm-hmm .
[doctor] . blood pressure go up . let's look at the readings .
[doctor] hey dragon ? show me the blood pressure readings .
[doctor] yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well .
[patient] mm-hmm .
[doctor] okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ?
[patient] sure .
[doctor] and kick against my hands .
[doctor] okay , good . all right .
[doctor] okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur .
[patient] mm-hmm .
[doctor] on your heart exam . which you've had in the past .
[patient] mm-hmm .
[doctor] so that sounds stable to me .
[doctor] on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ?
[patient] mm-hmm .
[doctor] hey dragon ? show me the diabetes labs .
[doctor] okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ?
[patient] sure .
[doctor] hey dragon ? show me the back x-ray .
[doctor] so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on-
[patient] mm-hmm .
[doctor] . the history , okay ?
[patient] mm-hmm .
[doctor] so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you .
[doctor] so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day .
[patient] mm-hmm .
[doctor] i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy-
[patient] mm-hmm .
[doctor] . and see how you do , okay ?
[patient] you got it .
[doctor] for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ?
[patient] mm-hmm .
[doctor] hey dragon ? order a hemoglobin a1c .
[doctor] so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day .
[patient] mm-hmm .
[doctor] does that sound okay ? i think we need to get it under better control .
[patient] no that's fine . i agree .
[doctor] hey dragon ? order lisinopril 20 mg daily .
[doctor] and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ...
[patient] mm-hmm .
[doctor] i do n't think we need to do any- any further , you know , work up of that at this time , okay ?
[patient] mm-hmm .
[doctor] do you have any questions logan ?
[patient] not at this point .
[doctor] okay . all right .
[doctor] so the nurse will come in to help you get checked out , okay ?
[patient] you got it .
[doctor] hey dragon ? finalize the note .","CHIEF COMPLAINT

Back pain.

HISTORY OF PRESENT ILLNESS

Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with back pain.

Mr. Walker reports that he was helping his daughter move some heavy equipment and lifted some heavy boxes a little too quickly on Saturday. He thought he heard a pop when he moved and he had to lie down for about an hour before his pain resolved. He has had stiffness ever since. The pain is located in his lower back. He took Tylenol, ibuprofen, and used Icy Hot on the area, but it did not seem to help. The patient endorses some tingling in his toes on his right foot, which resolved Sunday afternoon. He finds it difficult to find a comfortable position to sleep at night, and he tends to lie on his right side, which seems to help a little bit.

Regarding his diabetes type 2, Mr. Walker reports that he has not cooked a meal at home in weeks, due to travel. He notes that his diet has not been great, and he thinks he needs to eat clean for a couple of weeks.

He monitors his blood pressure at home and it is under control for the most part.

Regarding his osteoarthritis, Mr. Walker reports occasional aggravation of his knee when he runs too much or lifts boxes that are too heavy.

The patient denies chest pain, nausea, vomiting, fevers, and chills.

REVIEW OF SYSTEMS

• Constitutional: Denies fevers, chills.
• Cardiovascular: Denies chest pain.
• Musculoskeletal: Endorses back pain and stiffness. Endorses knee pain with exertion.
• Neurological: Endorsed tingling in toes until Sunday, denies tingling today.

PHYSICAL EXAMINATION

• Cardiovascular: Slight 2/6 systolic ejection murmur.
• Musculoskeletal: Pain to palpation of the lumbar spine. Pain with flexion and extension of the back. Negative straight leg raise.

VITALS REVIEWED

• Blood Pressure: Elevated

RESULTS

Hemoglobin A1c is elevated at 8.

X-ray of the back is unremarkable. Normal bony alignment. No fracture present.

ASSESSMENT AND PLAN

Mr. Logan Walker is a 58-year-old male with a past medical history significant for diabetes type 2, hypertension, and osteoarthritis, who presents today with low back pain.

Lumbar strain.
• Medical Reasoning: He injured his lower back while moving heavy boxes. His recent x-ray was unremarkable.
• Medical Treatment: Initiate meloxicam 15 mg once a day.
• Specialist Referrals: Referral to physical therapy.
• Patient Education and Counseling: He was encouraged to continue icing the area and avoid strenuous activity.

Diabetes type 2.
• Medical Reasoning: His recent hemoglobin A1c was elevated at 8. He does admit to some dietary indiscretion lately.
• Additional Testing: Repeat hemoglobin A1c in 6 months.
• Medical Treatment: Increase metformin to 1000 mg twice a day.

Hypertension.
• Medical Reasoning: His blood pressures have been slightly elevated based on home monitoring and in clinic today.
• Medical Treatment: Increase lisinopril from 10 mg to 20 mg a day.

Osteoarthritis.
• Medical Reasoning: This is mostly well controlled.
• Medical Treatment: Continue to monitor the knee. No further work up is needed at this time.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
"
virtassist,D2N071,"[doctor] i know the nurse told you about dax .
[patient] mm-hmm
[doctor] i'd like to tell dax a little bit about you , okay ?
[patient] sure .
[doctor] so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ?
[patient] um , relatively speaking , okay . it was kind of a , a tough spring with all the pollen and everything and , uh , we dropped my oldest daughter off at college and moved her into her dorm , so little stressful , little chaotic , in the heat of the summer , but so far , so good .
[doctor] okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing .
[patient] yeah .
[doctor] so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year .
[patient] yeah , i've been staying on top of the meds , and i have n't had any incidents in a while , so it's , it's been pretty good , and everything's managed and maintained . um , still kind of working with my hypertension . that's been a little bit more of a struggle than anything .
[doctor] okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ...
[patient] i ... i'm pretty regular with the medications during the business week , but on there's weekends , you know , if i'm on the fly or doing something , sometimes i forget , or i forget to bring it with me . uh , but for the most part , it's been okay .
[doctor] okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ?
[patient] other than during the heat and the pollen , it's been pretty good .
[doctor] okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ?
[patient] sometimes i , i regularly , uh , go for a run in the morning . that's my workout , and sometimes if it's , uh , relatively humid , i'll struggle a little bit , and i might feel a little bit of pounding in my chest . it usually goes away , but , uh , again , for the most part , it's been pretty good .
[doctor] okay , so you also have some shortness of breath with with exertion .
[patient] correct . correct .
[doctor] all right , and how far are you running ?
[patient] uh , like 4 to 5 miles a day .
[doctor] okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure .
[patient] mm-hmm .
[doctor] hey , dragon , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , dragon , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it has in the past , so continue on the current medication .
[patient] mm-hmm .
[doctor] all right , so i'm just gon na listen to your heart and lungs and check you out , okay ?
[patient] you got it .
[doctor] okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today .
[patient] mm-hmm .
[doctor] and in reviewing the results , it looks like your ekg is completely normal , so that's good .
[patient] good .
[doctor] so i'm not too concerned about that , that chest pounding . hey , dragon , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my assessment and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well-
[patient] mm-hmm .
[doctor] . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ?
[patient] uh , actually , i do need a refill .
[doctor] okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow up with the surgeon anymore . and then for your last problem , your hypertension .
[patient] mm-hmm .
[doctor] you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , dragon , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ?
[patient] perfect .
[doctor] all right . good to see you .
[patient] same here .
[doctor] hey , dragon , finalize the note . the nurse will be in .
[patient] thank you .","CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

The patient is a 62-year-old male with a past medical history significant for depression and prior lobectomy, as well as hypertension. He presents for his annual exam.

The patient reports that he is doing relatively well. Over the summer, he moved his oldest daughter into college which was a little stressful and chaotic in the heat of the summer.

Regarding his depression, he reports that he has been consistent with his Prozac and has not had any incidents in a while.

His hypertension has been slightly uncontrolled. He reports that he is taking his blood pressure at home and it is running high. The patient states that he is pretty regular with his Norvasc during the business week, but on the weekends he will forget to bring it with him.

He reports that he had a prior lobectomy a couple of years ago. He endorses shortness of breath with exertion. The patient has difficulty breathing due to allergies and the heat in the summertime. He also endorses some nasal congestion from the pollen. He reports that he runs in the morning. Occasionally, if it is relatively humid, he will struggle a little bit with breathing and he will feel a little bit of a pounding in his chest. He states that it usually goes away. He reports that he runs 4 to 5 miles a day.

REVIEW OF SYSTEMS

• Ears, Nose, Mouth and Throat: Endorses nasal congestion from the pollen.
• Cardiovascular: Endorses intermittent palpitations. Endorses dyspnea on exertion.
• Respiratory: Endorses shortness of breath. Endorses cough.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Head and Face: Pain to palpation to the sinuses.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate. 2/6 systolic ejection murmur. No gallops or rubs. No extra heart sounds.

VITALS REVIEWED
• Blood Pressure: 124/80 mmHg.

RESULTS

Electrocardiogram stable.

X-ray of the chest is unremarkable.

ASSESSMENT AND PLAN

Ralph Barnes is a 62-year-old male who presents for his annual examination.

Annual visit.
• Additional Testing: I have ordered his routine blood work and will follow up with the patient via the portal once results are back.

Depression.
• Medical Reasoning: He is doing well with his current regimen.
• Medical Treatment: He can continue Prozac 20 mg a day and I provided a refill of that today.

History of lobectomy.
• Medical Reasoning: I do not think we need to do any more work up for this issue. He is able to exercise a lot and his breathing function is back. I do not think he needs to follow up with the surgeon anymore.

Hypertension.
• Medical Reasoning: He is doing well on his current regimen. His blood pressure was normal today and has been trending well over the past several years.
• Additional Testing: I ordered an echocardiogram to evaluate his murmur.
• Medical Treatment: He can continue Norvasc.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
"
virtassist,D2N072,"[doctor] hi , ms. brooks . i'm dr. baker . how are you ?
[patient] hi , dr. baker .
[doctor] is your , is your right finger hurting ?
[patient] yes .
[doctor] okay . hey , dragon , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened .
[patient] well , i was skiing over the weekend-
[doctor] okay .
[patient] . and as i was , um , coming down the hill , i tried moguls , which jumping over those big hills , i tend to get my strap caught on my finger-
[doctor]
[patient] . and it kind of bent it back a bit .
[doctor] okay .
[patient] yeah .
[doctor] and when did this happen ?
[patient] it happened , uh ... that was sunday .
[doctor] okay . and have you tried anything for this or anything made it better or worse ?
[patient] i tried , um , putting ice on it .
[doctor] okay .
[patient] uh , and then i- i've been taking ibuprofen , but it's still very painful .
[doctor] okay . and , uh , is it worse when you bend it ? or anything make it ... so , just wh-
[patient] yeah , movement .
[doctor] okay .
[patient] yes .
[doctor] okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ?
[patient] um , i have been suffering from constipation recently .
[doctor] okay . all right . and do you take ... what medicines do you take for constipation ?
[patient] um , i've just been taking , um , mel- um ...
[doctor] miralax ?
[patient] miralax . that's it .
[doctor] okay . miralax is sufficient .
[patient] miralax . yes .
[doctor] and any surgeries in the past ?
[patient] i did have my appendix taken out when i was 18 .
[doctor] okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ?
[patient] no .
[doctor] okay . and how'bout right there ? no ?
[patient] no .
[doctor] right here ?
[patient] that hurts .
[doctor] all right . uh , can you bend your finger for me ?
[patient] yeah .
[doctor] all right . and how about extend it ? all right . and can you touch your thumb with it ?
[patient] yes .
[doctor] all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have some pain flexion as well . so , let's look at your x-rays . hey , dragon , show me the x-rays .
[doctor] all right . so , on this x-ray.
everything looks normal right now . uh , i do n't see any fractures . everything lines up pretty well . uh , so , your x-ray looks normal with no fractures . so , based on the x-ray and your exam , you have some tenderness right here . i think you've got a little contusion right here . there's no fracture on the tip of your finger . uh , so , the diagnosis would be a right hand , uh , index finger contusion on the tip of your finger , okay ? so , i would recommend we get you a s- uh , aluminum foam splint and we'll get you some motrin . uh , we'll give you 600 milligrams every six hours and we'll take that for about a week . and if it does n't get better , why do n't you call us and come back at that point ?
[patient] okay .
[doctor] okay . do you have any questions ?
[patient] no . i think that sounds good .
[doctor] okay . hey , dragon , order the medication and procedures we discussed . all right . and why do n't you come with me and we'll get you signed out .
[patient] okay . thank you .
[doctor] all right . finalize report , dragon .","CC:

Right finger pain.

HPI:

Ms. Brooks is a 48-year-old female who presents today for an evaluation of right finger pain. She states she was skiing on Sunday and hyperextended her finger when it became caught in a strap on a jump. She has tried applying ice and taking Ibuprofen, but it is still very painful. She has pain with movement.

CURRENT MEDICATIONS:

MiraLax

PAST MEDICAL HISTORY:

Constipation.

PAST SURGICAL HISTORY:

Appendectomy.

EXAM

Examination of the right index finger shows tenderness over the distal phalanx. No tenderness over the proximal phalanx or the MP joint. Pain with flexion.

RESULTS

X-rays of the right hand show no obvious signs of fracture or bony abnormalities.

IMPRESSION

Right hand index finger contusion at the tip of the finger.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a splint. She will take Motrin 600 mg every 6 hours for a week. If she does not improve, she will follow up with me. All questions were answered.
"
virtscribe,D2N073,"[doctor] today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia .
[doctor] hello , how are you ?
[patient] i'm good , thank you .
[doctor] so tell me what brings you in today .
[patient] recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic .
[doctor] or how have you been feeling in general with this ?
[patient] not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me .
[doctor] okay . are there any other symptoms ?
[patient] i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess .
[doctor] sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ?
[patient] yeah , i've been anemic since i was 13 years old .
[doctor] right . so why do your doctors think you're anemic ? do you have a history of heavy periods ?
[patient] well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly .
[doctor] yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ?
[patient] about five to six years ago .
[doctor] and was it relatively a normal exam ? did you have any polyps ?
[patient] no . they said they'd see me in 10 years .
[doctor] well that's good news .
[patient] yeah , i agree .
[doctor] um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ?
[patient] no .
[doctor] all right . do you ever drink alcohol ?
[patient] yeah , but only once or twice a year .
[doctor] okay . are you taking any supplements such as iron or vitamin b12 ?
[patient] i already started taking my iron pills which i have not taken in about a year .
[doctor] all right . and what are you taking ?
[patient] i'm taking 25 milligram tablets , twice daily .
[doctor] okay , and that's the , the ferrous sulfate ?
[patient] yeah , that's it . i take one in the morning and one in the evening .
[doctor] okay . anything else ?
[patient] yeah , i take vitamin b12 , just the over the counter stuff .
[doctor] okay , very good . all right , well let's go ahead and take a look and see what's going on .
[patient] sounds good . thank you .
[doctor] of course . you'll hear me , uh , talk through your exam so that i get all the information documented .
[patient] okay .
[doctor] all right . so use my general physical exam template . i will start by listening to your heart and lungs .
[patient] okay .
[doctor] all right . next , i'd like you to lay back so i can examine your abdomen .
[patient] okay .
[doctor] is there any tenderness where i'm pressing ?
[patient] no .
[doctor] okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding .
[patient] is that why they want me to have another upper endoscopy ?
[doctor] actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why .
[patient] lovely .
[doctor] yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system .
[patient] okay .
[doctor] we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better .
[patient] all right .
[doctor] so let's go ahead , get your upper endoscopy and colonoscopy scheduled .
[patient] okay .
[doctor] um , have you ever had any issue with sedation in the past ?
[patient] no , i was just sleepy afterwards .
[doctor] okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy .
[patient] okay . sounds like a plan .
[doctor] all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work .
[patient] okay , that sounds great .
[doctor] all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have any questions or worsening symptoms . we'll be happy to help you .
[patient] thank you .
[doctor] you're welcome . have a great day , have a great day ms. cooper .
[patient] you too .
[doctor] all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .","CHIEF COMPLAINT

Iron deficiency anemia.

HISTORY OF PRESENT ILLNESS

Mrs. Christina Cooper is a 65-year-old female who presents with a long-history of iron deficiency anemia.

The patient reports she has been living with anemia since she was 13 years old. She attempted to donate blood on 12/2019 but was unable to due to her anemia. She has a history of heavy menstruation and a hysterectomy in 1996. She completed a colonoscopy 5-6 years ago with nonsignificant findings. She denies having a pacemaker, defibrillator, sleep apnea, or using oxygen.

Mrs. Cooper reports a myriad of symptoms, stating she feels fatigued often during the day, feverish with chills at times, and during activity feels she cannot catch her breath and some wheezing is present. She has been having some headaches which is uncommon for her. Additionally, she is noticing tingling sensations, cold sensitivity, and her anxiety and depression have worsened.

PAST HISTORY

Surgical
Hysterectomy, 1996.

Procedures
Colonoscopy 5-6 years ago.

SOCIAL HISTORY

Drink’s alcohol 1-2 times per year.

CURRENT MEDICATIONS

Ferrous Sulfate 25 mg tablet twice per day (1 in the morning, 1 in the evening), Vitamin B12 OTC.

PHYSICAL EXAM

Gastrointestinal
Abdomen non-tender.

ASSESSMENT

• Iron deficiency anemia

Mrs. Cooper is a 65-year-old female who was diagnosed with iron deficiency anemia in 12/2019 and was unable to donate blood. Her follow-up blood work in 01/2020 revealed a low hemoglobin, stable hematocrit, and normal iron labs, although, ferritin was low. She has been taking ferrous sulfate 325 mg by mouth.

PLAN

I have asked her to continue each ferrous sulfate dose with vitamin C found in orange juice for the next 12 weeks then recheck CBC, iron ferritin, B-12, and folate. A referral was sent for her to see a hematologist. We will plan for EGD and colonoscopy to assess for potential sources of anemia or GI bleed. If this is inconclusive, capsule endoscopy can be considered.

INSTRUCTIONS

Schedule upper endoscopy, colonoscopy and appointment with hematologist. Return to the clinic if symptoms worsen."
virtscribe,D2N074,"[doctor] patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable .
[doctor] worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . the mri reveals a pituitary lesion with elevation and compression of the optic chiasm . the ventricles are normal in size and no other abnormalities are lo- are noted .
[doctor] hello , mr . ward . nice to meet you . i'm dr. flores .
[patient] hi , doc . nice to meet you .
[doctor] i was just reviewing your records from dr. howard and he's referred you because the workup for headaches revealed a mass on your pituitary gland . i did review your mri images and you have a significant mass there . can you tell me about the issues you've been experiencing ?
[patient] yeah sure . so i'm really getting fed up with these headaches . i've been trying my best to deal with them but they've been going on for months now and i'm really struggling .
[doctor] where are the headaches located and how would you describe that pain ?
[patient] located behind my eyes . it's like a dull nagging ache .
[doctor] okay . was the onset gradual or sudden ?
[patient] well it started about three months ago . and they've been getting worse over time . at first it was like three out of 10 severity , and it just gradually worsened . and now it's about six out of 10 severity . the headaches do tend to be worse in the morning and it feels like a dull ache behind the eyes . they last a few hours at a time , nothing makes them better or worse .
[doctor] okay . can you tell me if the pain radiates , or if you have any other symptoms ? specifically feeling sick , fever , rashes , neck stiffness , numbness , weakness , passing out ?
[patient] no . i have n't been sick or felt sick . ca n't recall a fever or any kind of rash . no- no neck issues , no numbness , no tingling . and i've never passed out in my life . but , um , for some reason recently i seem to be bumping into door frames .
[doctor] okay . have you noticed any change in your vision or with your balance ?
[patient] no i do n't think so . my eyes were checked in the fall .
[doctor] okay . let's see , do you have any other medical problems that you take medicine for ?
[patient] no i do n't have any medical problems and i do n't take any medicines . i tried tylenol a few times for the headaches but it did n't work , so i stopped .
[doctor] i see . anyone in your family have any history of diseases ?
[patient] i was adopted so i really have no idea .
[doctor] okay . um , what kind of work do you do ? and are you married ?
[patient] i work as a computer programmer and i've been married for 25 years . we just bought a small house .
[doctor] that's nice . um , do you drink any alcohol , smoke , or use recreational drugs ?
[patient] nope . i do n't do any of those and never have .
[doctor] okay . um , well let me take a good look at you . um , now you'll hear me calling out some details as i perform the examination . these will be noted for me in your record and i'll be happy to answer any questions you have once we're done .
[patient] sounds good , doc .
[doctor] all right . the patient is alert , oriented to time , place , and person . affect is appropriate and speech is fluent . cranial nerve examination is grossly intact . no focal , motor , or sensory deficit in the upper or lower extremities . visual acuity and eye movements are normal . pupils are equal and reactive . visual field testing reveals bitemporal hemianopia . and color vision is normal .
[doctor] all right , mr. ward . i'm going to review these pictures from the mri with you . um , now this appears to be a benign pituitary adenoma , but there's no way to be sure without sending the removed adenoma to pathology to make the diagnosis , which we will do . um , here you can see it's a well defined mass . and it's pressing right here on what we call the optic chiasm . and today when i was having you look at my fingers , you could n't see them off to the sides , that's what we call bitemporal hemianopia . and explains why you have been bumping into door frames .
[patient] yeah i never noticed that i could n't see out of the side until you did that test , and you closed one eye with both eyes . i really could n't tell .
[doctor] no because you're having this vision loss from the mass compressing the optic chiasm , the only option we have is to do surgery .
[patient] okay , i understand . do you think i'll regain my vision ?
[doctor] well there's no guarantees , but it is a possibility . i'm gon na refer you to the eye doctor for a full exam and they'll do what's called visual field test . this will map our your peripheral vision or side vision prior to surgery . and we can monitor after surgery to see if your vision is improving .
[patient] all right .
[doctor] and let's discuss the surgery a little more . um , we would do what's called a transsphenoidal approach to do the surgery . this is minimally invasive and we go through the sphenoid sinus . there are some risks i have to inform you of . uh , risk of anesthesia including but not limited to the risk of heart attack , stroke , and death . risk of surgery include infection , need for further surgery , wound issues such as spinal fluid leak or infection , uh , which may require long , prolonged hospitalization or additional procedure . uh , seizure , stroke , permanent numbness , weakness , difficulty speaking , or even death .
[patient] well i guess we have to do it regardless .
[doctor] okay . so i will have you see our surgery scheduler , deborah , on the way out to get you set up . we will get this scheduled fairly quickly so i do n't want you to be alarmed . um , she'll also get you set up today or tomorrow to have the visual field test and you may not be able to see the eye doctor until after surgery . but we have the pre-surgery visual field test for comparison after surgery .
[patient] okay . i look forward to these headaches going away . i never thought it could be something like this going on .
[doctor] yeah . come this way , we'll get your things lined up . please call if you think of any questions .
[patient] thanks , doctor .
[doctor] diagnosis will be pituitary adenoma . mr . ward is a very pleasant 52-year-old male who has benign appearing pituitary adenoma , incidentally discovered during workup for worsening headaches . he is symptomatic with clinical and radiographical evidence of optic chiasmal compression , therefor surgical intervention to excise and decompress the pituitary fossa is indicated . end of note .","CHIEF COMPLAINT

Pituitary lesion.

HISTORY OF PRESENT ILLNESS

Bruce Ward is a 52-year-old male with a pituitary lesion. The patient is seen in consultation at the request of Dr. Henry Howard for possible surgical intervention.

The patient presented to his primary care provider, Dr. Howard, on 03/01/2021 complaining of worsening headaches over the past few months. He denied any trouble with headaches in the past. Further work up of headaches with MRI of the brain revealed the pituitary lesion.

Mr. Ward reports headaches started about 3 months ago, at which point they were around 3 out of 10 in severity. They have gradually worsened over time and now he rates them at about 6/10. The headaches do tend to be worse in the morning and feel like a dull ache behind the eyes. They tend to last a few hours at a time, and nothing makes them particularly worse or better. Tylenol failed to improve headaches.

The patient endorses that recently he has been bumping into door frames, but no obvious problems with his balance or vision. He denies any recent sickness or feeling sick and negative for fever, rash, paresthesia, weakness, neck stiffness, or syncope.

PAST HISTORY

Medical
Newly diagnosed pituitary lesion.

FAMILY HISTORY

No known family history; adopted.

SOCIAL HISTORY

Employment Status: Works as a computer programmer.
Marital Status: Married for 25 years.
Living Arrangement: Lives with wife, recently purchased a new house.
Alcohol Use: None.
Tobacco Use: Non-smoker.
Recreational Drugs: None.

PHYSICAL EXAM

Neurological
Patient alert, oriented to person, place, and time, affect appropriate and speech fluent. Cranial nerve examination grossly intact. No focal motor or sensory deficit in the upper or lower extremities.

Eyes
Visual acuity and eye movements are normal. Pupils are equal and reactive. Visual field testing reveals bitemporal hemianopia. Color vision is normal.

RESULTS

Labs reviewed, 03/03/2021: CBC, U&Es, coagulation, and CRP are all normal. Pituitary hormone profile demonstrates a low TSH, all other results were normal.

Independent review and interpretation of MRI brain, 03/04/2021: The MRI reveals a pituitary lesion with elevation and compression of the optic chiasm. The ventricles are normal in size and no other abnormalities are noted.

ASSESSMENT

• Pituitary adenoma
• Bitemporal hemianopia

Mr. Ward is a very pleasant 52-year-old male who has a benign appearing pituitary adenoma discovered on work up for worsening headaches. There is clinical and radiographical evidence of optic chiasmal compression, examination today revealed a bitemporal hemianopia. Radiographically this appears to be a benign pituitary adenoma but that there was no way to be sure without a pathological diagnosis. Surgical intervention to excise and decompress the pituitary fossa is indicated given optic chiasmal compression.

PLAN

Pituitary adenoma.
We discussed the general indications for surgical intervention. The risks, benefits to trans-sphenoidal resection were explained to the patient. The risks of anesthesia including but not limited to the risks of heart attack, stroke, and death. The risks of surgery including infection, need for further surgery, wound issues (such as spinal fluid leak or infection) which may require prolonged hospitalization or additional procedure, seizure, stroke, permanent numbness, weakness, difficulty speaking, or death. The patient voiced understanding and wishes to proceed with trans-sphenoidal resection of the adenoma.

Bitemporal hemianopia.
We will have the patient scheduled this week to have visual field testing with ophthalmology. The preoperative visual field will serve as baseline for comparison of postoperative visual field testing to monitor for improvement in the bitemporal hemianopia. Additionally, we discussed that unfortunately no guarantees could be given that his vision would return.

INSTRUCTIONS

• Refer to ophthalmology for baseline visual field testing.
• Schedule trans-sphenoidal resection of pituitary adenoma.
"
virtscribe,D2N075,"[doctor] next is betty hill , uh , date of birth is 2/21/1968 . she has a past medical history of uterine fibroids and anemia . she's a new patient with a referral from the er of esophagitis . um , i reviewed our records from the er , including the normal cardiac workup , and we're about to go in and see her now . good morning . you miss hill ?
[patient] good morning . yes . that's me .
[doctor] hey , i'm dr. sanders . it's nice to meet you .
[patient] nice to meet you too .
[doctor] so tell me about what brings you in today ?
[patient] well , i really needed to see you three months ... three months ago , but this was your first available appointment . when i called to make the appointment , i was having chest pains , but it stopped after four days , and i have n't had any since then .
[doctor] okay . when did these four days of chest pain occur ?
[patient] um , early october .
[doctor] of 2020 , correct ?
[patient] yes .
[doctor] okay . can you think of anything that might have caused the chest pain ? did you wake up with it ?
[patient] no . it just it randomly . i tolerated it for four days but then had to go to the emergency room because nothing i did relieved it . they did a bunch of testing and did n't find anything .
[doctor] okay . can you point to the area of your chest where the pain was located ?
[patient] well , it was here in the center of my chest , right behind my breastbone . it felt like i was having a heart attack . the pain was really sharp .
[doctor] did they prescribe you any medications in the er ?
[patient] no . they ran an ekg and did blood tests , but like i said , everything was normal .
[doctor] okay . i see .
[patient] they thought it was something to do with the gi system , so that's why they referred me here .
[doctor] interesting . uh , do you remember having any heartburn or indigestion at , at the time ?
[patient] uh , maybe . i do n't think i've ever had heartburn , so i'm not sure what that feels like .
[doctor] was the pain worse with eating or exercise ?
[patient] yes . with eating .
[doctor] okay . any difficulty swallowing ?
[patient] mm-hmm . i did .
[doctor] okay . and that's also resolved since the initial episode three months ago ?
[patient] yes . thankfully . the chest pain and swallowing problem got better about three days after i went to the er . but i just feel like there's something wrong .
[doctor] okay . so how has your weight been .
[patient] i've been trying to lose weight .
[doctor] that's good . any in- ... issues with abdominal pain ?
[patient] uh , no .
[doctor] okay . good . and how about your bowel movements ; are they okay ?
[patient] they're normal .
[doctor] all right . are you aware of any family history of gi problems ?
[patient] i do n't think so .
[doctor] have had you had any surgeries on your abdomen , or gall bladder , or appendix ?
[patient] yes . they took my gall bladder out several years ago .
[doctor] okay . if you wan na lay down here on the table for me and lets take a look at you .
[patient] okay .
[doctor] so when i push on your lower belly , do you have any pain , or does it feel tender ?
[patient] no .
[doctor] okay . how about up here in your upper abdomen ?
[patient] yes . it , it hurts a little .
[doctor] okay . and even when i press lightly like this ?
[patient] yes . uh , just a little uncomfortable .
[doctor] okay . does it hurt more when i press over here on the left or over here on the right ? or is it about the same ?
[patient] i'd say it's about the same .
[doctor] okay . so we'll say you have some mild tenderness to light palpation in the upper abdominal quadrants , but everything on your exam looks normal and looks good .
[patient] okay . good .
[doctor] so let's talk about your symptoms real quick . obviously , with the chest discomfort , we worry about heart issues , but i'm reassured that those were ruled out with all the testing they did in the er . um , other potential causes could be anxiety , esophagitis , which is irritation of the esophagus . but typically with these , um ... but typically , these cause the pain that would last for a long time rather than that isolated incident like you had . um , it's also possible that you had intense heartburn for a few days .
[patient] well , since you mention anxiety , i was going through a really stressful job transition right around the time this happened .
[doctor] okay . that's good to know . so stress from this could be , um ... could be , uh ... could be very well have contributed to your condition .
[patient] okay .
[doctor] so we could do an , uh , egd or upper endoscopy to take a look at your esophagus and stomach . this would allow us to look for esophagitis . but your symptoms occurred three months ago and you have n't had any additional episodes , so likely if it were esophagitis , it's already healed by the point ... by this point , and we would n't be able to see anything . the other option is just to continue to monitor , uh , for any additional symptoms at which point we could do the egd . uh , with you being asymptomatic for so long right now , i'm comfortable with that option . but what do you think ?
[patient] i'd like to hold off on the egd and wait to see if i have more symptoms .
[doctor] that sounds good . um , so you can call the office if you have any additional episodes of pain or any other symptoms you're concerned about . if that happens , we'll get you scheduled for an egd to take a look . if not , you can follow up with me ... follow up with me as needed for any other gi complaints .
[patient] okay .
[doctor] all right ? if you do n't have any questions for me , i'll walk you out to the check-out desk .
[patient] no . that's it . thank you .
[doctor] you're welcome . right this way . all right . uh , in assessment , please summarize the patient's history briefly , and let's list her possible etiologies such as , uh , gerd , dyspepsia , esophagitis , musculoskeletal etiologies , and anxiety . uh , suspect she had an anxiety attack related to her job transition , plus or minus a contribution from her musculoskeletal etiologies . um , in the plan , include our discussion of the egd versus monderning ... monitoring for symptom . patient elected to self-monitor her symptoms and will call with any reoccurrence or change . thanks .","CHIEF COMPLAINT

Esophagitis.

HISTORY OF PRESENT ILLNESS

Betty Hill is a 53 y.o. female who presents to clinic today for a new patient evaluation of suspected esophagitis. The patient was referred from the emergency department where she was seen in early 10/2020 following 4 days of chest pain. The pain has resolved but she kept this appointment to discuss the original 4-day episode.

The patient describes her chest pain in early 10/2020 as sharp and localized behind the sternum. She states that it felt like a heart attack and the onset was sudden. The pain was exacerbated by eating and accompanied by dysphagia. The patient is not able to say whether she had heartburn as she has never experienced heartburn before and is unsure what it feels like. When asked about potential triggers, the patient identifies that she was experiencing a lot of stress at that time due to a job transition. She was able to tolerate the chest pain and dysphagia for 4 days but reports that nothing she tried relieved her symptoms. She then presented to the emergency department and underwent labs and EKG. All results came back normal from these tests. She was not prescribed any medications in the emergency department but was given a referral to me for suspected esophagitis. Her chest pain and dysphagia resolved spontaneously approximately 3 days after her emergency department visit and has not recurred.

The patient denies unintentional weight loss, weight gain, abdominal pain, constipation, and diarrhea. She states she is trying to lose weight.

PAST HISTORY

Medical
Uterine fibroids.
Anemia.

Surgical
Cholecystectomy.

FAMILY HISTORY

None reported.

REVIEW OF SYSTEMS

• Cardiovascular:  Positive for chest pain.
• Gastrointestinal:  Positive for difficulty swallowing.
• Psychiatric:  Positive for stress.

PHYSICAL EXAM

Gastrointestinal
Mild tenderness to light palpation in the upper abdominal quadrants.

RESULTS

The patient’s emergency department records from her 10/2020 visit were reviewed, including the normal cardiac workup.

ASSESSMENT

The patient presents today following a visit to the emergency department in early 10/2020 for 4-days of sharp chest pain, made worse by eating, and dysphagia. Notably, the patient was experiencing higher levels of stress than normal for her at that time due to a job transition. Her cardiac evaluation in the emergency department was normal and she was referred to me for suspected esophagitis. The patient’s pain and associated dysphagia spontaneously resolved 3 days after her emergency department visit and has not recurred. Possible etiologies of her chest pain and dysphagia include GERD, dyspepsia, esophagitis, musculoskeletal etiologies, and anxiety. Based on her history today, I suspect she had an anxiety attack related to her job transition, plus or minus a contribution from musculoskeletal etiologies.

Non-cardiac chest pain.

Suspected etiology of anxiety with or without underlying musculoskeletal etiology.

PLAN

• We discussed the role of an EGD in evaluating her prior symptoms. Given her current asymptomatic status, I am comfortable foregoing the EGD for now in lieu of continued monitoring for symptom recurrence. The patient agreed to notify my office if her symptoms return at which time, we could schedule the EGD. The patient is agreeable to this plan.

INSTRUCTIONS

• Self-monitor for symptom recurrence and notify my office if this occurs.
• Follow up as needed."
virtscribe,D2N076,"[doctor] hello .
[patient_guest] hi .
[doctor] i'm dr. evelyn , one of the kidney doctors . it's good to meet you guys .
[patient_guest] it's nice to meet you also .
[doctor] yeah . so i was reading about this syndrome that i actually have never heard of .
[patient_guest] yeah , me too .
[doctor] i do n't think it's very common .
[patient_guest] definitely not . it's c- pretty rare .
[doctor] so-
[doctor] can you start at the beginning ? i know she's a twin , so are these your first two babies ?
[patient_guest] no , i have a son also who is nine . he also has autism .
[doctor] okay .
[patient_guest] and when the twins were born , katherine , she was about 4 pounds , 8 ounces . and her twin was a bit smaller , at 3 pounds , 13 ounces .
[patient_guest] katherine , she was doing fine . she just had problems with eating , where she would stop breathing when she was eating .
[doctor] like preemie type stuff ?
[patient_guest] uh- . yeah . she just had a hard time regulating her temperature , but she did fine . she does have a gi doctor , because she has reflex really bad . she also had a dietician , who told us to take her off cow's milk . which we did . and then she has seen an allergist , and also a neurologist ... who diagnosed her with this syndrome , because she still does n't walk and she was n't sitting by herself a year old .
[doctor] yeah .
[patient_guest] but so now she is crawling and she is trying to take steps , so think she's doing pretty good .
[doctor] good . is she in therapy ?
[patient_guest] she is in therapy . she's in feeding therapy , occupational therapy , and also physical therapy .
[doctor] awesome . okay .
[patient_guest] and we also have speech therapy , who is going to be starting within the next couple of weeks .
[doctor] that's great .
[patient_guest] so , she has a lot of therapies . we have also seen an orthopedic and an ophthalmologist . i can never say that . we have seen everything , really .
[doctor] and audiology too , right ?
[patient_guest] yes .
[doctor] yeah , wow. .
[patient_guest] yeah , it has definitely been a whirlwind of stuff . when we saw the geneticist , she told us that sometimes people with this syndrome , they have trouble with their kidneys . that they might actually fuse into one . she also said sometimes they have problems with their legs , so that was why we saw ortho .
[doctor] okay . okay .
[patient_guest] so we have seen everybody , really . we are just here to make sure that her kidneys are looking good right now .
[doctor] yeah , okay . so , um , tell me about how many wet diapers she has in a 24 hour period ?
[patient_guest] she has a lot .
[doctor] so like normal 8 to 10 , or like 20 ?
[patient_guest] yeah , it's around 8 to 10 .
[doctor] okay . great .
[patient_guest] yeah , she seems to pee a lot , and it feels like she drinks a lot too .
[doctor] that's perfect .
[patient_guest] and she used to only drink milk , and then i took her off dairy milk . so when i say milk , i actually mean , you know , ripple pea protein milk .
[doctor] sure , yeah .
[patient_guest] so i give her that milk , water now that she's used to it , and sometimes water with just a little bit of juice . so i do feel like she's drinking a lot better now .
[doctor] that's great . and she's how old now ?
[patient_guest] she'll be two mo- two next month .
[doctor] okay . is her twin a boy or a girl ?
[patient_guest] she's a girl .
[doctor] okay , and how's she doing ?
[patient_guest] she's doing really good . she's running around , and she does n't have any problems .
[doctor] all right . is she bigger than her or the same size ?
[patient_guest] they're about the same size . they're able to wear the same clothes , so ...
[doctor] okay .
[patient_guest] i do n't even think she's a pound hav- heavier , actually .
[doctor] yeah . yeah .
[patient_guest] but she is a little bit taller than her ... um , katherine . she's just sh- a little shorter and chunkier , but i think that's a part of her syndrome .
[doctor] yeah . yeah , i was reading all the things associated with the syndrome . it sounds like we're looking for continual- congenital anomalies wi- of the kidney and urinary tract . which is basically something is wrong with the plumbing .
[patient_guest] okay .
[doctor] so the only way to know that , is to do a kidney ultrasound .
[patient_guest] okay , that sounds okay .
[doctor] okay . let me put that into the system , and then downstairs they can do the ultrasound .
[patient_guest] all right , thank you .
[doctor] okay , yeah . where do you all live ?
[patient_guest] uh , we live in dallas .
[doctor] okay . anybody in the family with kidney failure , dialysis or transplant ?
[patient_guest] no .
[doctor] okay . so let's get your ultrasound done , and we'll see how it goes .
[patient_guest] all right , that sounds good .
[doctor] all right . let me take a quick look at her .
[patient_guest] sure .
[doctor] all right . please use my physical exam template . um , i wan na take a quick listen to her heart and lungs . i'll look in her ears too . and she can sit , she can just sit on your lap .
[patient_guest] okay .
[doctor] all right . that's it .
[patient_guest] all right , that was n't too bad .
[doctor] hmm . so , let's complete the ultrasound today . i'll call you with the results . if it's normal , you wo n't need to see me again , but if it's abnormal , you can see me in kennesaw .
[patient_guest] okay , that sounds good .
[doctor] okay . we'll determine what the next steps are if there are any , after we see her results .
[patient_guest] all right , sounds good . thank you .
[doctor] you're welcome . the nurse will be in to have you complete some paperwork , and give you instructions for the ultrasound . we'll talk soon .
[patient_guest] all right . thank you , and have a good day .
[doctor] you too .
[doctor] all right . physical exams show the well-nourished female , who is slightly fussy when examined . eyes are small appearing . she has mild hypotonia of the lower extremities in her arms . normal external female genitalia .
[doctor] assessment and plan . katherine is a 22-month-old former 34 and 3-week-old , twin with smith magenis syndrome . several organ systems can be affected by this chromosomal deletion syndrome . congenital anomalies of the kidney and urinary tract have been reported in the literature .
[doctor] we will obtain the screening of the kidneys by ultrasound today . if there are abnormalities on the kidney ultrasound , we will determine next steps and future follow-up . the family lives in dallas , georgia , so her follow-up should be at the town center location .
[doctor] end of recording .","CHIEF COMPLAINT

Renal screening tests.

HISTORY OF PRESENT ILLNESS

Katherine Lopez is a 22-month-old female, born at 34 weeks +3 days gestation, diagnosed with the rare Smith-Magenis syndrome and associated global developmental delays. She was referred to nephrology by genetics who recommended renal screening tests. At birth, the patient weighed 4 pounds 8 ounces, exhibited difficulties during eating where she would stop breathing, and challenges regulating her body temperature; determined to be typical issues associated with premature birth. The patient has seen many specialists, including GI for severe reflux, a dietitian who recommended discontinuing consumption of cow’s milk, and a neurologist who diagnosed her with Smith-Magenis syndrome. Additionally, she has been seen by a geneticist, orthopedist, ophthalmologist, and audiologist. The patient is not ambulatory, did not sit up unassisted until 1 years old, and is currently crawling and attempting to take steps. She will be starting speech therapy in the next few weeks, and currently she is in occupational, feeding, and physical therapy. The geneticist informed the patient's mother that patients with Smith-Magenis syndrome usually have kidney issues where “the kidneys fuse into one” and issues with their legs.

The patient has approximately 8 to 10 wet diapers in a 24-hour period. Her mother notes that she is doing better with drinking fluids and she urinates “a lot”. The patient drinks Ripple Pea Protein milk instead of cow’s milk, water and water mixed with a small amount of juice. Her twin sister is approximately the same size, and their weight is essentially the same, she is healthy, and the mom denies any known health concerns or diagnoses. The mom states that Katherine is shorter and seems chubbier related to her syndrome. She also has a 9-year-old brother who is diagnosed with autism.

BIRTH HISTORY

Twin gestation. Birth weight 4 pounds 8 ounces.

PAST HISTORY

Medical
Smith-Magenis syndrome.

SOCIAL HISTORY

Patient accompanied to appointment by her mother.
Sibling: 9-year-old brother and twin sister.

FAMILY HISTORY

Brother: 9 years old, positive for autism.
Twin sister: absence of Smith-Magenis syndrome, no known health conditions.
No known family history of genetic conditions, kidney failure, dialysis, or kidney transplant.

PHYSICAL EXAM

Constitutional
Well-nourished female, slightly fussy when examined.

Eyes
Presences of microphthalmia.

Genitourinary
Normal external female genitalia.

Musculoskeletal
Extremities: Presence of mild hypotonia of lower extremities and the arms.

ASSESSMENT

• Smith-Magenis syndrome.
Katherine is a 22-month-old former 34+3-week-old twin with Smith-Magenis syndrome.
Several organ systems can be affected by this chromosomal deletion syndrome and congenital anomalies of the kidney and urinary tract have been reported in the literature.

PLAN

We will obtain a kidney ultrasound screening today. If there are abnormalities on the kidney ultrasound, we will determine the next steps and future follow-up. The family lives in Dallas, Georgia, so her follow-up should be at the Town Center location.

INSTRUCTIONS

Complete ultrasound today. I will call patient with results and possible next steps."
aci,D2N077,"[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.
"
aci,D2N078,"[doctor] hey philip good to see you today so take a look here at my notes i see you're coming in for some right knee pain and you have a past medical history of hypertension and we will take a look at that so can you tell me what happened to your knee
[patient] yeah i was you know i was just doing some work on my property and i i accidentally slipped and fell down and i just still having some knee issues
[doctor] okay well that that's not good do you
[patient] no
[doctor] what part of your knee would you say hurts
[patient] i would just say you know the it it you know it basically when i when i'm flexing my knee when i'm moving it up and down and i put pressure on it
[doctor] alright did you hear a pop or anything like that
[patient] i did feel something pop yes
[doctor] okay and did it was it swollen afterwards or is it looks a little bit swollen right now
[patient] yeah little bit swollen yeah
[doctor] okay so so far have you taken anything for the pain
[patient] just taking some ibuprofen just for some swelling
[doctor] okay that's it what would you say your pain score is a out of ten with ten being the worst pain you ever felt
[patient] i would say that when i'm stationary i do n't really feel a lot of pain but if i start doing some mobility i would say probably a four five
[doctor] about a four okay and how long ago did you say this was is this happened this injury
[patient] it's been a week now
[doctor] a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly
[patient] yes i have
[doctor] okay so you might have a little white coat syndrome i know some of my patients definitely do have that so what about your diet i know we talked a little bit before about you reducing your sodium intake to about twenty three hundred milligrams per per day i know you were during the pandemic your diet got out of little bit out of control so how have you been doing how have you been doing with that
[patient] i definitely need some help there i have not have not made some some changes
[doctor] okay yeah we definitely need to get you to lower that salt intake get your diet a little bit better because the hope is to get you off that medication and get your blood pressure to a manageable level okay so we yeah we definitely can talk about that alright so lem me take a look at your knee i'll do a quick physical exam on you and before i do just want to make sure you're not having any chest pain today
[patient] no
[doctor] are you any belly pain
[patient] no
[doctor] no shortness of breath just wan na make sure
[patient] no
[doctor] okay so i'm just gon na listen to your lungs here your lungs are clear bilaterally i do n't hear any wheezes or crackles listen to your heart so on your heart exam i do still hear that grade two out of six systolic ejection murmur and you already had that and so we we knew about that already so lem me look at your knee here so when i press here on the inside of your knee does that hurt
[patient] a little bit
[doctor] little bit how about when i press on the outs the outside gon na press on the outside is that painful
[patient] no
[doctor] no alright so i'm gon na have you flex your knee is that painful
[patient] yeah that's uncomfortable
[doctor] that's uncomfortable and extend it so that's painful
[patient] yeah yes
[doctor] okay so on your knee exam i i see that you do have pain to palpation of the medial aspect of your right knee you have some pain with flexion extension i also identify some edema around the knee and some effusion you have a little bit of fluid in there as well so prior to coming in we did do an x-ray of that right knee and luckily you did n't break anything so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you have what we call a mcl strain so a medial collateral ligament strain so when you fell i think you twisted a little bit and so it irritated you strained that that ligament there so for that what we can do for you first i'm gon na prescribe you some ibuprofen eight hundred milligrams and you can take that twice a day and that's gon na help you with that swelling and that pain that you currently do have i'm also gon na put you in a a knee brace just to try and support those muscles to allow it to heal and then i want you to ice the knee you can do that for twenty minutes at a time for three to four times a day that should also help with the the swelling of your knee for your hypertension now i'm gon na keep you on that twenty of lisinopril okay because you are taking it and you you're doing pretty good with it i also want to get you a referral to nutrition just to try to help you with that diet you know because right now you are your diet is little bit out of control so we just need to rain you in a little bit and hopefully you know with their help we can eventually get you off that lisinopril alright so do you have any questions for me
[patient] do i need to elevate my leg or stay off my leg or
[doctor] yeah i would yeah you can elevate your leg stay off your stay off your leg you know if you have any kids have them work out in the yard instead of you just to to for a couple of weeks it's a good thing if you want to do that
[patient] tell him this doctor's order
[doctor] tell definitely tell him his doctor tell him i said it
[patient] alright do you have any other questions no that's it i appreciate you seeing me
[doctor] alright so my nurse will be in with the those orders and we will see you next time","CHIEF COMPLAINT

Right knee pain.

REVIEW OF SYSTEMS

Cardiovascular: Denies chest pain.
Respiratory: Denies shortness of breath.
Gastrointestinal: Denies abdominal pain.
Musculoskeletal: Reports right knee pain.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally. No wheezes.

Cardiovascular
- Auscultation of Heart: Grade 2/6 systolic ejection murmur. Some edema and effusion noted around the right knee.

Musculoskeletal
- Examination: Right knee
- Palpation: Pain to palpation of the medial aspect. No pain to palpation of the lateral aspect.
- ROM: Pain with flexion and extension.
-Some effusion noted around the right knee.

RESULTS

X-rays of the right knee were taken. These show no fractures or bony abnormalities.

ASSESSMENT AND PLAN

1. Right knee MCL strain.
- Medical Reasoning: Based on the physical examination findings, the patient has a MCL strain of the right knee. - Medical Treatment: I have prescribed ibuprofen 800 mg twice a day. I will also place him in a knee brace. I advised him to ice the knee for 20 minutes at a time for 3 to 4 times a day. The patient was instructed to elevate his leg as needed and avoid strenuous activities for 2-3 weeks.

2. Hypertension.
- Medical Treatment: The patient will continue lisinopril 20 mg daily. I have also provided a referral to see a nutritionist for dietary changes.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan."
aci,D2N079,"[doctor] hi wayne how're you today
[patient] i'm doing okay aside from this left shoulder pain that i've been having
[doctor] okay and how long have you had this pain
[patient] about i want to say a few weeks i think it's been about three weeks now
[doctor] okay and do you remember what you were doing when the pain started
[patient] honestly i've been trying to recall if i had any specific injury and i ca n't think of that
[doctor] okay
[patient] of anything the only thing i can think of is that i you know i am active and we've just been doing a lot of work in our basement so if i do n't know if i did something while doing that
[doctor] okay alright tell me have you ever had pain in that shoulder before
[patient] you know i i'm really active and so i i will get some aches and pains here and there but nothing that tylenol ca n't take care of
[doctor] okay good but now are you able to move your arm
[patient] you know i have trouble when i'm trying to reach for something or lift any objects and i do n't even try to reach it for anything over my head because then it'll really hurt
[doctor] okay alright and and now are you having the pain all the time or does it come and go
[patient] the pain is always there and then it gets worse like if i try to put any pressure on it it gets worse so if i'm laying at night if i try to even lay on that shoulder it's unbearable
[doctor] okay and then tell me what have you taken for your pain
[patient] i've been taking two extra strength tylenol every six to eight hours
[doctor] alright and and did that help
[patient] it does take the edge off but i still have some pain
[doctor] okay well i'm sorry to hear that you know you know renovating the basement it can be quite a task and it can take a toll on you
[patient] yeah i mean it's been fun but yeah i think it really did take a toll on me
[doctor] yeah what what are you doing with your basement are you are you doing like a a man cave or
[patient] yeah yeah that's exactly right
[doctor] that is awesome great well that sounds like fun i hope you get to set it up just the way you you would like for your man cave to be so congratulations to you there so tell me have you experienced any kind of numbness in your arms or in your hands
[patient] no no numbness or tingling
[doctor] okay alright so let's just go ahead and do a quick physical exam on you here i did review your vitals everything here looks good now lem me take a look at your shoulder alright now on your left shoulder exam you have limited active and passive range of motion and how does that feel here
[patient] that hurts
[doctor] okay sorry there is tenderness of the greater tuberosity of the humerus but there is no tenderness at the sternoclavicular or acromioclavicular joints you have good hand grips alright and then now on your neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is intact to light touch alright so what does that all mean well firstly lem me go ahead and take a look at your results of your shoulder x-ray here now i reviewed the results and there are no fractures so that's good so let's go ahead and talk about my assessment and plan here wayne so for your problem of left shoulder pain your symptoms are most likely due to a rotator cuff tendinopathy so this means that you injured the tendons of the muscles that help make up your shoulder muscles so i will be ordering an mri for your left shoulder to be sure that there is nothing else going on with your shoulder okay
[patient] okay
[doctor] now i'm also going to refer you to physical therapy for approximately six to eight weeks and during that time you may also continue to take tylenol now if your symptoms do n't improve we can consider a steroid injection for your shoulder which can provide some relief do you have any questions about your plan at all
[patient] so do you think this pain will ever go away
[doctor] now well many patients are very successful with the physical therapy those will those help strengthen you know they do a lot of strengthening exercises with you to help strengthen you know your muscles so that it's not your movements not always relying on those joints predominantly so we're gon na go ahead and start with that and then see how you do okay
[patient] okay okay
[doctor] alright okay well do you have any other questions for me
[patient] no i think that's it
[doctor] okay well i'm gon na have the nurse check you out and she's also gon na give you some educational materials on the physical therapy and what to expect and and then go ahead and schedule a follow-up visit with me as well after you you do your physical therapy okay
[patient] okay
[doctor] alright well have a good day
[patient] okay you too
[doctor] thanks
[patient] okay bye","CHIEF COMPLAINT

Left shoulder pain.

HISTORY OF PRESENT ILLNESS

Wayne Taylor is a pleasant 66-year-old male who presents to the clinic today for the evaluation of left shoulder pain. The onset of his pain began 3 weeks ago. He denies any specific injury. The patient states he is active and has been renovating his basement. He reports a history of intermittent aches and pains in his left shoulder. He has difficulty reaching for or lifting any objects. He adds that he avoids reaching overhead secondary to the pain. The patient describes his pain as constant and worsening. He notes his pain is unbearable when lying on his left shoulder at night. He denies any numbness or tingling in the bilateral upper extremities. He has been taking 2 Extra Strength Tylenol every 6 to 8 hours, which provides some relief.

REVIEW OF SYSTEMS

Musculoskeletal: Reports left shoulder pain. Neurological: Denies numbness or tingling in the bilateral upper extremities.

VITALS

All vital signs are within the normal limits.

PHYSICAL EXAM

Capillary refill is less than 3 seconds.

NEURO: Normal sensation. Sensation is intact to light touch in the left upper extremity.
MSK: Examination of the left shoulder: Limited active and passive ROM. Tenderness over the greater tuberosity of the humerus. No tenderness at the sternoclavicular or acromioclavicular joints. Good hand grip.

RESULTS

X-rays of the left shoulder were obtained and are reviewed today. These reveal there are no fractures.

ASSESSMENT

Left shoulder pain, most likely due to rotator cuff tendinopathy.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that his symptoms are most likely due to rotator cuff tendinopathy. I recommend obtaining an MRI of the left shoulder to further assess the rotator cuff. I will also refer him to formal physical therapy to strengthen his left shoulder for approximately 6 to 8 weeks. The patient was provided with educational materials regarding expectations related to his physical therapy. He may continue to take Tylenol as needed. If his symptoms do not improve with physical therapy, we will consider a steroid injection to the left shoulder. All questions were answered.

INSTRUCTIONS

The patient will follow up with me after he has completed his course of physical therapy."
aci,D2N080,"[doctor] okay hi andrea well i
[patient] hello
[doctor] i understand you're you've come in with some right knee pain can you tell me about it what's going on
[patient] it it's not the right knee it's the left knee
[doctor] okay the left knee
[patient] and it just happens occasionally less than once a day when i'm walking all of a sudden it is kind of like gives out and i think here i'm going to fall but i usually catch myself so lot of times i have to hold a grocery cart and that helps a lot so it comes and goes and it it passes just about as quickly as it comes i do n't know what it is whether i stepped wrong or i just do n't know
[doctor] okay well so where does it hurt like in on the inside or the outside or
[patient] internally and it it just the whole kneecap fades
[doctor] okay well did you hear or feel a pop at any point
[patient] no
[doctor] okay
[patient] like that
[doctor] have you ever had any type of injury to that knee i mean did you fall or bump it against something or
[patient] no not that i can recall
[doctor] okay and have is it painful have you taken anything for for pain
[patient] no because it does n't last that long
[doctor] okay
[patient] it just like i said it just it goes about as fast as i came in
[doctor] so is it interfering with your just things you like to do and
[patient] hmmm no not really
[doctor] so i know you said that you like to do a lot of travel
[patient] yeah i've got a trip planned here in the next month or so and we are going down to columbus georgia to a a lion's club function and probably be doing a lot of walking there and they got some line dances planned and i do n't think i will be able to participate in that because of the knee
[doctor] is that where you would be kicking your leg out or something
[patient] no it's do n't you know what line dancing is like dancing in theories of fairly fast moves but it's mostly sideways motion
[doctor] and is and that you think that's when your knee might give out then or just not gon na take the chance
[patient] not gon na take the chance
[doctor] okay yeah that sounds like a good idea have you thought about even having a a cane just in case or do you think that's does that happen often enough
[patient] wrap it i would n't be able to keep track of it so no no pain
[doctor] okay okay well so since you're in how about your blood pressure how how is it doing and have you been taking your blood pressures at home like we talked about
[patient] yes they are doing fine still about the same
[doctor] so
[patient] correct that whatever
[doctor] so what has it been running
[patient] i ca n't really remember it's been several days since i took it but i think it runs around one twenty over seventy somewhere along in there
[doctor] okay alright and so what about your medication we have you on some medication for your blood pressure right
[patient] yes i take take them regularly at eight thirty in the morning and eight thirty at night
[doctor] and what is the medication and the dosage that you are taking
[patient] i'm taking a farxiga and amlodipine
[doctor] okay
[patient] and lisinopril and the hydrochlorothiazide so i i ca n't pronounce that one so but those are all small dosage pills
[doctor] that but yeah go ahead
[patient] no that was it i just take them regularly eight thirty in the morning eight thirty at night
[doctor] yeah well that's good i i know you said you set an alarm on your phone to make sure that you get them taken at the right time so that's really good and how are your blood sugars doing how is your diet doing
[patient] my blood sugar has been running a little higher at about one thirty
[doctor] is that in the morning when you're fasting
[patient] yes
[doctor] okay
[patient] and i have been told that sometimes the morning blood sugars are higher for some reason but i do n't know i i do n't really worry about it as long as it does n't get up too extremely high so
[doctor] and are you taking your metformin
[patient] yes yes that's along with the blood pressure medicine morning and night
[doctor] okay alright so are you are you eating like late at night or anything like that
[patient] no we usually eat by six
[doctor] okay okay alright well hopefully we can get you to feeling better okay so i want to do a quick physical exam really check that knee out so your vital signs look good they they look alright your temperature is ninety eight . two your pulse is seventy two respirations are sixteen blood pressure is one twenty two over seventy so that looks fine i'm gon na go ahead and take a listen to your heart and lungs so on your heart exam it's a nice regular rate and rhythm but i appreciate a slight two over six systolic ejection murmur at the left base here on your lung exam your lungs are clear to auscultation bilaterally okay now let's take a quick look at that knee so does it hurt when i press on it
[patient] no
[doctor] okay can you bend your knee and straighten it out
[patient] yes
[doctor] okay i'm gon na do some maneuvers and i'm gon na just gon na call out my findings on this okay on your right knee exam no ecchymosis or edema no effusion no pain to palpation of the of the left medial knee is there any decreased range of motion do you feel you feel like you're you're able to fully move that as you should the same as the other knee
[patient] yeah
[doctor] okay so no decreased range of motion negative varus and valgus test okay and so with your x-rays i reviewed the result of your left knee x-ray which showed no evidence of fracture or bony abnormality so lem me tell you a little bit about my plan so your left knee pain i think you just have some arthritis in that i want to prescribe some meloxicam fifteen milligrams a day we might do some physical therapy for that just to strengthen the muscles around that area and prevent any further problems with that okay and so for your second problem the hypertension so i wan na continue the lisinopril at twenty milligrams a day and order an echocardiogram just to evaluate that heart murmur alright and
[patient] okay
[doctor] for the diabetes mellitus i wan na order a hemoglobin a1c to see if we need to make any adjustments to your metformin and i'm also gon na order a lipid panel okay do you have any questions
[patient] no i do n't think so when will all this take place
[doctor] we will get you scheduled for the echocardiogram i will have my nurse come in and we will get that set up okay","CHIEF COMPLAINT

Left knee pain.

HISTORY OF PRESENT ILLNESS

Andrea Barnes is a 34-year-old female who presents today for evaluation of left knee pain.

The patient has been experiencing intermittent episodes of pain and sudden instability with ambulation. Her pain is localized deep in her patella and occurs less than once daily. Due to the fleeting nature of these episodes, she has not taken medication and simply braces herself until it passes. She denies any trauma or injury, or ever hearing or feeling a pop in the knee. Her symptoms do not interfere with her daily activities and she does not use a cane.

Regarding her hypertension, it has been several days since she last checked her blood pressure at home, but it was approximately 120/70 mmHg at that time. Her current medications include amlodipine, lisinopril, and hydrochlorothiazide, all of which she takes on a regular basis.

In terms of her diabetes, her fasting morning blood glucose levels have been approximately 130 based on home monitoring. This is slightly higher than usual, even though she has been compliant with metformin and Farxiga. She does try to avoid eating late at night.

MEDICAL HISTORY

Patient reports a personal history of hypertension and type 2 diabetes.

SOCIAL HISTORY

Patient likes to travel and is planning a trip to Columbus, Georgia in the next month or so. She is part of the Lion's Club.

MEDICATIONS

Patient reports that she is taking amlodipine, lisinopril 20 mg once daily, hydrochlorothiazide, Metformin, and Farxiga.

REVIEW OF SYSTEMS

Musculoskeletal: Reports left knee pain and instability,

VITALS

Temperature: 98.2 degrees F
Heart rate: 72 bpm
Respirations: 16
Blood pressure: 122/70 mmHg

PHYSICAL EXAM

MSK: Examination of the right knee: No ecchymosis or edema. No effusion. No pain with palpation.
Examination of the left knee: Full range of motion. Negative varus and valgus stress test.

RESULTS

X-rays were obtained and reviewed today. These reveal no evidence of fracture or bony abnormality.

ASSESSMENT

1. Left knee pain.
2. Hypertension.
3. Diabetes mellitus type 2.

PLAN

After reviewing the patients x-rays, I believe there is some arthritis in the knee. I'm going to prescribe meloxicam 15 mg once daily. We can consider physical therapy to strengthen the muscles around the area to prevent any further issues.

Her hypertension is well controlled with her current medication regimen. She can continue with lisinopril 20 mg once daily. I'm also going to order an echocardiogram for further evaluation of the murmur heard on exam.

She has been compliant with metformin as prescribed, but her blood glucose levels have been slightly elevated recently. I'm going to order a lipid panel, as well as a hemoglobin A1c to determine if any adjustments need to be made to her dose of metformin."
aci,D2N081,"[doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three nonsmile cell lung cancer who presents for follow-up during neo agit chemotherapy she was diagnosed with a four . four centimeter left upper lobe nodule biopsy was positive for adenocarcinoma molecular testing is pending at this time alright hello beverly how are you
[patient] i'm good today
[doctor] you're good today yeah you've been going through a lot lately i know you just had your treatment how how are your symptoms
[patient] my symptoms are pretty good today i just kind of have a minimal cough and a sore throat
[doctor] okay
[patient] but that's all i'm feeling today
[doctor] okay and how about fatigue have you been feeling more tired
[patient] yes a little bit
[doctor] okay and how about any nausea or vomiting
[patient] no not as of today
[doctor] okay and i know you were mentioning a cough before how is it as far as walking are you having any shortness of breath
[patient] i have n't noticed any shortness of breath it just kind of seems to be a lingering kind of light dry cough
[doctor] cough okay is it any mucus with it or is it a dry cough
[patient] more dry
[doctor] a dry cough okay and tell me more about this sore throat
[patient] this kind of seems to be persistent comes and goes it will be worse sometimes and then others it feels better trying to drink lots of fluids
[doctor] okay
[patient] to see if it can it you know the dry coughing if it's part of that or what i can do
[doctor] okay and when you mention drinking and eating is do you feel like anything is getting stuck there
[patient] no i do n't feel like anything is getting stuck right now and i have n't been i have been eating but not as much as i normally would
[doctor] okay okay alright and how are you doing as far as like just emotionally and mentally how are you doing i'm just talking a little bit about your support systems
[patient] the nursing staff and the office has been very good to help you know with anything that i need as far as support so just since we are just getting started so far on the journey i do feel like i have support and mentally you know still feel strong
[doctor] okay and how about with family or friends have you been able to turn to anyone
[patient] i do have good family members that have been supportive and they have come to my treatment with me
[doctor] okay excellent excellent and so right now you're on a combination of two different chemotherapies the cisplestan as well as the eupside and you had your last treatment just a few days ago but you're saying right now you've been able to tolerate the nausea and the fatigue
[patient] yes i have n't had any nausea but you know just slight fatigue it does n't seem to be overwhelming
[doctor] okay okay so we are gon na go ahead if it's okay with you and start your physical exam reviewing your vitals so vitals look good especially your oxygen especially with the chemotherapy you've been getting and the cough so your oxygen looks good so i'm happy with that so now i'm just examining your neck especially with your sore throat and i do n't appreciate any cervical lymphadenopathy and also no supraclavicular adenopathy listening to your heart you have a nice regular rate and rhythm with no murmurs that i appreciate now on your lung exam when you're taking some deep breaths i do notice some crackles in your lungs bilaterally and what that means is there is there is some faint sounds that i'm hearing which could represent some fluid there so on looking at your skin exam on your chest you do have some erythema on the anterior side of the chest on the left side and this could be related to the radiation so on your lower extremities i appreciate no edema and everything else looks good and thank you i know you did a chest x-ray before coming in so on your results for the chest x-ray it does look like you have some mild radiation pneumonitis which basically means some inflammation of the lungs most likely due to the radiation so what does this all mean so for your assessment and plan so for the first diagnosis the first problem of the lung cancer so what we're gon na do is we're gon na continue with the current regimen of your chemotherapy of the cisplacin and the etoside and we're gon na continue with your current dose of radiation at forty five grade and when that's complete we will repeat some imaging and hopefully you know the tumor will shrink down enough that we can remove it surgically okay for problem number two so the radiation pneumonitis so that's what causing that cough as well as some of the shortness of breath i know you're not experiencing it much now so what i'm gon na do for that is actually gon na prescribe you a low dose of prednisone and so that's an will help with the inflammation i'm gon na give you forty milligrams daily for five days and so hopefully that will help reduce the inflammation and so that you can continue with the radiation okay how does that sound so far
[patient] that sounds great thank you
[doctor] okay and then lastly for the painful swallowing that you're having so the inflammation you're having it not only in your lungs but it also in your esophagus as well so what i'm gon na do is prescribe you you're taking the the prednisone i'm also gon na give you a lidocaine swish and swallow and you can do that four times a day and so that will be able to help you so you can eat immediately after taking it and it can also help so that you can continue to take food and fluids prevent dehydration and any further weight loss
[patient] great
[doctor] okay any questions for me
[patient] i do n't believe so at this time
[doctor] okay alright so i'll see you at your next visit
[patient] great thank you
[doctor] you're welcome and so now just","CHIEF COMPLAINT

Follow up of stage III non-small cell lung cancer.

MEDICAL HISTORY

Patient reports history of stage III non-small cell lung cancer.

SOCIAL HISTORY

Patient reports having a good family support system and that some of her family has accompanied her to her chemotherapy sessions.

MEDICATIONS

Patient reports she is currently receiving chemotherapy treatment consisting of Cisplatin and etoposide.

REVIEW OF SYSTEMS

Constitutional: Reports fatigue and decrease in appetite.
HENT: Reports sore throat. Denies dysphagia.
Respiratory: Reports dry cough. Denies shortness of breath.
Gastrointestinal: Denies nausea or vomiting

VITALS

Vitals are within normal limits including oxygen saturation.

PHYSICAL EXAM

Neck
No cervical lymphadenopathy or supraclavicular adenopathy.

Respiratory
- Auscultation of Lungs: Crackles heard bilaterally.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs.

Musculoskeletal
- Examination: No edema.

Integumentary
- Erythema noted on the anterior side of the chest on the left side possibly related to radiation.

Hematology/Lymphatic/Immunology
- Palpation: No enlarged lymph nodes.

RESULTS

Chest x-ray is reviewed and demonstrates mild radiation pneumonitis.

ASSESSMENT AND PLAN

1. Stage III non-small cell lung cancer.
- Medical Reasoning: The patient has a recent diagnosis of stage III non-small cell lung cancer. Biopsy was positive for adenocarcinoma. Molecular testing is pending at this time.
- Medical Treatment: We are going to continue with the current regimen of combination chemotherapy consisting of Cisplatin and etoposide. We are also going to continue with her current dose of radiation at 45 Gy. Once this is complete, we will obtain repeat imaging in hopes that the tumor will decrease in size enough for surgical removal.

2. Radiation pneumonitis.
- Medical Reasoning: The patient is experiencing a persistent dry cough. Recent x-rays are reviewed and demonstrated evidence of mild radiation pneumonitis.
- Patient Education and Counseling: We discussed the etiology of her dry cough is from her mild radiation pneumonitis.
- Medical Treatment: A prescription of prednisone 40 mg daily for 5 days is provided to help with her inflammation.

3. Painful swallowing.
- Medical Reasoning: The patient is experiencing painful swallowing secondary to inflammation of the esophagus.
- Patient Education and Counseling: We discussed the etiology of her painful swallowing and that a lidocaine viscous solution will be beneficial in preventing dehydration and any further weight loss.
- Medical Treatment: A lidocaine viscous solution was provided to be performed 4 times daily.

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

INSTRUCTIONS

The patient will return to clinic at her next scheduled follow up."
aci,D2N082,"[doctor] alright
[patient] you're ready just
[doctor] ready
[patient] hi kyle how are you today
[doctor] i'm doing well i'm just anxious about my pcp told me that i had some abnormal lab work and why she wanted me to be seen by you today
[patient] yeah i bet that did make you nervous i i see that she referred you for a low immunoglobulin a level is that your understanding
[doctor] yeah i mean i do n't even really understand what that means but yeah that's what she told me
[patient] yeah that's a mouthful
[doctor] yeah
[patient] it it's the the one of the antibodies in your body and that that really makes that your body makes to fight infections it's a little bit low i'm happy to explain it a little bit more to you i just have a few more questions okay so let's start again here
[doctor] i'll do this
[patient] i i think i would break that
[doctor] yeah i just saw that
[patient] if you can do that
[doctor] okay
[patient] yeah so we'll we'll just
[doctor] okay
[patient] you can leave it the way it is for now i just i think break that up
[doctor] okay alright so yeah that sounds fine for me
[patient] yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections
[doctor] yeah yeah i had a recent physical and she did this as part of her my physical i do tend to get infections but i do n't know i i'm so used to it so i do n't know if this is more than usual in the wintertime i get a lot of colds and they do seem to i always say that my colds kind of linger for a long time but i do n't know if it's more than usual
[patient] okay how about any abdominal infections
[doctor] diarrhea no
[patient] frequently
[doctor] no not that i can not that i say can think of
[patient] okay what about your family are are anyone in your family that you know have immune deficiencies
[doctor] no my family is actually pretty healthy
[patient] okay and how about do you have any other medical conditions
[doctor] yeah my pcp just started me on metformin i just got diagnosed with type two diabetes
[patient] okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street
[doctor] yes and that's probably part of the cause of my diabetes yes
[patient] yeah well i guess you're gon na have to watch that
[doctor] i know i know
[patient] but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away
[doctor] right
[patient] but have you ever needed to receive a blood transfusion or blood products
[doctor] no i actually tried to give blood but they i did n't qualify because i had recently traveled internationally
[patient] okay where did you go
[doctor] i was in zambia
[patient] hmmm i heard that's beautiful
[doctor] it's so beautiful it's so beautiful i had a great time
[patient] okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial
[doctor] no
[patient] no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about the assessment and plan so for your first problem the that a iga deficiency is it very common immunodeficiency your your body makes many different types of antibodies in one of your z iga is just a little bit lower than normal now most of the time people live their entire life without even knowing they have that deficiency and function perfectly normal now some people may find that they get tend to get frequent respiratory tract or sinus or abdominal infections but this does n't necessarily seem to be the case for you now it can go along with other immunodeficiencies but i think there is a low likelihood hood in your case but we're gon na order some additional blood work that includes checking those other antibodies now do you have any questions on what i just told you
[doctor] yeah so is there anything i need to do or should be watching for or should i be worried
[patient] no i i really do n't think you need to be worried now we're gon na check these additional studies and that will give us some more guidance but really i think this is just a finding that's common to you and you know it it's many people have have have these type of you know immunodeficiency what i want you to watch for is those infections that do n't stop you have trouble getting it under control or you know any changes to your abdominal tract you know severe diarrhea
[doctor] anything like that then you know we may want to look at it a little bit further but for now i do n't think there is anything significant we want to do now go ahead and get your lab work and
[patient] bring you in for that now the only other thing that i would say is if you eat end up needing any blood products between now and when i see you next make sure you tell them that you have that iga deficiency
[doctor] why is that
[patient] well there is a risk that your body can strongly react to some blood products and they just need to know that so they're prepared so anytime you get blood just make sure you say that you have a history of a an an iga deficiency
[doctor] okay okay thank you
[patient] you're welcome
[doctor] okay","HISTORY OF PRESENT ILLNESS

Kyle Lee is a pleasant 46-year-old male who presents to the clinic today for evaluation of low immunoglobulin A level. He was referred to our offices by his primary care physician after routine labs revealed abnormalities. The patient states he has been experiencing frequent infections. During the winter months, he experiences frequent colds that tend to linger, however this is not uncommon for him. The patient denies abdominal issues or diarrhea.

The patient was recently diagnosed with type 2 diabetes. He is currently taking metformin.

MEDICAL HISTORY

Patient denies a history of blood transfusions.

SOCIAL HISTORY

He recently traveled internationally on a trip to Zambia. His family owns a local doughnut shop.

FAMILY HISTORY

Patient denies a family history of immune deficiencies.

REVIEW OF SYSTEMS

Gastrointestinal: Denies abdominal issues or diarrhea.

VITALS

Temperature: Normal.
All other vitals were reviewed and are within normal limits.

PHYSICAL EXAM

NECK: No swelling noted. No lymphadenopathy.
CV: Normal heart rhythm with no murmurs.
RESPIRATORY: Lungs are clear. There's no wheezes, rales, or rhonchi.
Gastrointestinal: Abdomen is soft and without tenderness.

RESULTS

I did review the results of her recent lab work. It is consistent as her primary care physician noted with an IgA deficiency.

ASSESSMENT

IgA deficiency.

PLAN

After reviewing the patient's examination today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that the results of his recent lab work is consistent with an IgA deficiency. I have recommended that we obtain additional blood work to check his other antibodies. I encouraged the patient to be aware of lingering infections or abdominal changes including diarrhea. If he experiences these issues, he should report them to my office so we may investigate further, however I do not believe there is a need for that at this time. In the meantime, he should report this IgA deficiency in the event that he needs any blood transfusions. Questions were invited and answered today."
aci,D2N083,"[doctor] hey lawrence how're you doing
[patient] i'm doing alright aside from this elbow pain
[doctor] so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain
[patient] so i really during this pandemic i really got into ceramics and doing pottery so i've been doing a lot of pottery and over the past week i then started to develop this elbow pain
[doctor] okay and then so tell me a little bit more about that elbow pain where does it hurt exactly
[patient] you know it hurts a lot in the inside of my elbow
[doctor] okay so the inside of your right elbow okay
[patient] yeah
[doctor] and then does the pain radiate down your arm or up into your shoulder or anything like that
[patient] it does n't go into my shoulder it's it stays mostly at my elbow but it can go down a bit into my forearm
[doctor] okay and then do you remember any trauma did you hit your arm or elbow or any on anything
[patient] no nothing i i really was trying to think if there is anything else and i ca n't think of anything
[doctor] okay and you've never injured that right elbow before
[patient] no
[doctor] alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life
[patient] i would say probably a six
[doctor] okay and does that pain keep you up at night
[patient] it does
[doctor] okay and when you have that kind of pain does it keep you from doing other type of activities
[patient] yeah i mean i still try to like work through with using my arm but yeah it's it's it's difficult for me sometimes to lift and do things because of that pain
[doctor] okay and then and how long has this pain been going on
[patient] about four days now
[doctor] alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief
[patient] i've tried ibuprofen that helps a little but not much
[doctor] okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here
[patient] yes i do
[doctor] okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that
[patient] not really
[doctor] okay now turn your wrist in so do you have any pain when you do that
[patient] yeah that hurts
[doctor] okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist
[patient] yes i do
[doctor] alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend
[doctor] that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay
[patient] alrighty
[doctor] alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week
[patient] alright thank you
[doctor] thank you","CHIEF COMPLAINT

Right elbow pain.

HISTORY OF PRESENT ILLNESS

Lawrence Butler is a pleasant 45-year-old male who presents to the clinic today for the evaluation of right elbow pain.

Over the past week, the patient has developed 6/10 pain in the ""inside"" of his right elbow. The pain may radiate into his forearm on occasion, but does not extend up to his shoulder. He denies any history of trauma or injury, but he did start making pottery during the COVID-19 pandemic and suspects that his symptoms could be related to that. His symptoms affect his ability to lift objects or perform his typical activities of daily living. Ibuprofen provides minimal symptomatic relief.

SOCIAL HISTORY

The patient reports that he began making pottery during the COVID-19 pandemic.

MEDICATIONS

The patient reports that he has been taking ibuprofen.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right elbow pain.

VITALS

Normal

PHYSICAL EXAM

MSK: Examination of the right elbow: Moderate tenderness at the medial epicondyle. No pain with supination of the forearm. Pain with pronation of the forearm. Pain with resistance against flexion of the wrist.

RESULTS

X-ray imaging of the right elbow was obtained and reviewed in office today. These reveal no evidence of fracture or bony abnormality.

ASSESSMENT

Right medial epicondylitis.

PLAN

The patient and I discussed his diagnosis in detail, and I explained that his symptoms are likely caused by overuse and potential damage of the tendons. We will provide him with sling to be worn during the day while he is awake. I want him to take ibuprofen 600 mg every 6 hours with food for a full week and ice the elbow for 20 minutes, 3 times daily. Finally, I advised the patient to rest his elbow and avoid doing any pottery for the next couple of weeks.

INSTRUCTIONS

The patient will follow up in 1 week."
aci,D2N084,"[doctor] alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened
[patient] well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then all of a sudden i'm here
[doctor] hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath
[patient] i did but i did n't think anything of it
[doctor] sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on
[patient] i have but i miss them every year and then so i think today i took one
[doctor] okay alright yeah i have you on bumex cozaar and norvasc does that sound right
[patient] i guess so that sounds about right
[doctor] alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that
[patient] i've just been eating anything honestly i try to watch it here and there but to tell you the truth i'd looks i was eating
[doctor] yeah i i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or
[patient] little bit of everything here and there i do lot of chips
[doctor] sure
[patient] they're pretty good i guess they're salty even though the light salt ones but
[doctor] mm-hmm
[patient] kinda whatever i can get my hands on really
[doctor] okay alright how are you feeling right now
[patient] i'm doing a little okay i guess i'm just out of breath a little bit but it's nothing i ca n't handle
[doctor] sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those
[patient] no i have n't got one yet i know i needed to get one
[doctor] yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately
[patient] just like i said when i was walking outside it helped a little bit but again i just walked it off
[doctor] sure any problems sleeping
[patient] no i sleep like a rock
[doctor] good good to hear have you had any chest pain
[patient] slightly here or there but i thought it was just heartburn
[doctor] sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that
[patient] i've been pretty good on it very once every week maybe just one
[doctor] okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay
[patient] that sounds good document
[doctor] awesome weigh yourself daily do you have a scale at home
[patient] no but i can get one
[doctor] okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good
[patient] that sounds good to me
[doctor] great okay david do you have any other questions
[patient] no other questions at this time just i guess i just need to make sure to take my medication on time that's about it
[doctor] yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well
[patient] i will do my best
[doctor] alright thanks hope you feel better
[patient] thank you","CHIEF COMPLAINT

Follow up.

SOCIAL HISTORY

The patient has been trying to limit his tobacco use for 2 years. He reports smoking once every week.

MEDICATIONS

Bumex 2 mg once daily.
Cozaar 100 mg daily.
Norvasc 5 mg once daily.

REVIEW OF SYSTEMS

Constitutional: Denies problems sleeping.
Cardiovascular: Reports chest pain.
Respiratory: Reports shortness of breath.
Musculoskeletal: Reports bilateral ankle swelling.

VITALS

Blood pressure is 128/72 mm Hg. Other vital signs are within normal limits.

PHYSICAL EXAM

Neck
- General Examination: No JVD

Respiratory
- Auscultation of Lungs: Clear bilaterally.

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

Musculoskeletal
- Examination: Lower extremities show trace edema.

RESULTS

An echocardiogram, obtained at an outside facility, was reviewed today. It demonstrates a preserved ejection fraction of 55%. Normal diastolic filling. Mild to moderate mitral regurgitation.

ASSESSMENT AND PLAN

1. CHF.
- Medical Reasoning: The patient’s recent epsiode resulting in the emergency room visit was likely caused by his dietary indiscretion and uncontrolled hypertension that we have been monitoring.
- Patient Education and Counseling: I reviewed the echocardiogram results with the patient and discussed the importance of following dietary restrictions. I encouraged the patient to take his medication on a consistent basis. I advised him to purchase a scale to weigh himself daily.
- Medical Treatment: He will continue Bumex 2 mg once daily. He was provided with a referral to a nutritionist in consultation for further assistance with his dietary requirements to lower his sodium intake.

2. Hypertension.
- Medical Reasoning: This is currently uncontrolled.
- Patient Education and Counseling: I explained the importance of taking his medication on a daily basis. I encouraged the patient to purchase a blood pressure cuff and track his blood pressures.
- Medical Treatment: He will continue Cozaar 100 mg daily as well as the Norvasc 5 mg once daily. I will order a renal artery ultrasound for further evaluation.

3. Systolic ejection murmur.
- Medical Reasoning. Stable.

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

INSTRUCTIONS

The patient was instructed to call me if he gains 3 pounds in 2 days."
aci,D2N085,"[doctor] hi russell how are you what's been going on
[patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days
[doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee
[patient] yeah it kinda burns a little bit
[doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay
[patient] okay
[doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you","CHIEF COMPLAINT

Right-sided abdominal pain

MEDICAL HISTORY

Patient reports history of kidney stones.

FAMILY HISTORY

Patient reports his father has a history of kidney stones.

MEDICATIONS

Patient reports use of Tylenol.

REVIEW OF SYSTEMS

Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting
Genitourinary: Reports dysuria and dark colored urine. Denies hematuria.

PHYSICAL EXAM

Gastrointestinal
- Examination of Abdomen: No masses or tenderness to palpation. No rebound or guarding. No peritoneal signs. Positive CVA tenderness on the right flank.

RESULTS

Previous CT scan of the abdomen ordered by the patient's PCP is reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter. There is no evidence of hydronephrosis.

ASSESSMENT AND PLAN

1. Acute nephrolithiasis.
- Medical Reasoning: The patient presents with complaints of right-sided abdominal pain. His previous CT scan was reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter without evidence of hydronephrosis.
- Medical Treatment: I have recommended that he push fluids in order to help facilitate urination to help pass the stone. He will be provided with a strainer to allow us to potentially test the stone if he is able to pass it. I have also prescribed oxycodone 5 mg every 6 to 8 hours as needed for pain. He can continue to alternate oxycodone with Tylenol. A basic metabolic panel, urinalysis, and urine culture will also be ordered.

INSTRUCTIONS

He will follow up in 1 to 2 weeks. If he is still having symptoms at that time, we will discuss further treatment such as lithotripsy or ureteroscopy. He is to contact me if he is having worsening symptoms over the next week."
aci,D2N086,"[doctor] hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that
[patient] yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some burning and some stinging and looked down and saw a blister i did n't think too much of it because it was on the pad of the bottom of my foot around my heel and i just had been walking on the front part of my foot i started to notice a foul smell and my wife mentioned something to me the other day and i noticed my dog was also smelling my socks a lot and so we looked and saw that the blister had become unroofed or the the top part of the skin of the blister became undone and then underneath it was just this really thick soft mushy skin that had a bad smell with some yellow drainage and so and barbara called the primary care doctor who then got me in to see you he started me on some antibiotics about six days ago and i never had any nausea or vomiting but my wife checked my temperature it was about ninety nine point seven and then at one point i had to put on an extra blanket in bed because i had some chills and when i started the antibiotics it started to feel pretty good but we've now noticed that it has turned black around the outside of the wound and i'm getting some cramping in my calf muscle as well and so there was a red streak also that was coming up the front part of my my ankle along the inside portion of my calf muscle and it's super super hot and so they wanted me to take a have have you look at it
[doctor] okay thank you for sharing that history with me and did you complete that course of antibiotics
[patient] i think he called in ten days' worth and i'm on day six or seven right now i know i've got about two or three days left
[doctor] okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now
[patient] yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point
[doctor] okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that
[patient] yeah my my a1c is six point seven it's pretty well controlled
[doctor] okay
[patient] i used to be on an insulin pump and i had an a1c that at one point was like thirteen but we worked with an endocrinologist to get it down to where it's at now i've been six point seven for probably two years now and i rarely have a blood sugar that goes over two hundred i check two or three times a day if i feel weird i'll check it again but i noticed my sugars have probably been trending in the three to four hundreds the last two weeks and then i had one spike at one point at like five or six hundred that got our attention and i think that's also what made my wife call the primary care doc
[doctor] okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park
[patient] yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now
[doctor] absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there
[patient] i do n't feel that right there
[doctor] okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure
[patient] no not really so you're gon na continue the antibiotics that i'm on and possibly extend or call in a new antibiotic depending on the culture
[doctor] correct
[patient] if i heard
[doctor] yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy
[patient] okay sounds good
[doctor] alright","CHIEF COMPLAINT

Non-healing ulcer on his right foot.

HISTORY OF PRESENT ILLNESS

Nicholas Gutierrez is a pleasant 45-year-old male who presents to the clinic today for the evaluation of a non-healing ulcer on his right foot. The patient was referred from his primary care physician. The onset of his pain began 6 weeks ago, after wearing a pair of shoes that were too tight.

Today, he describes a burning, stinging, and throbbing sensation. The patient reports a blister on the pad of the plantar aspect of his foot around his heel. He explains that he has been ambulating on the anterior aspect of his foot. He explains that the top part of the skin of the blister detached, which revealed a thick, soft, mushy skin associated with unpleasant smell and yellow drainage. The patient called his primary care physician, who referred him to our office. He was prescribed a 10-day course of antibiotics approximately 6 days ago. He experienced chills and a fever of 99.7 degrees Fahrenheit. The patient denies any nausea or vomiting. He states that when he started the antibiotics, his foot began to feel pretty good. However, he has now noticed that his foot has turned black around the outside of the wound, and he is experiencing cramping in his calf muscle as well. He also reports a burning red streak that was coming up the front part of his ankle along the inside portion of his calf muscle. While palpating his calf, he has noted stiffness in the muscle that is now up to the patella. The patient reports that he has been coughing a lot over the last 2 days. He has experienced shortness of breath with ambulation around the house. He reports that he purchases new diabetic shoes yearly and changes the inserts every 3 to 4 months.

The patient is diabetic and has diabetic neuropathy. He explains that his blood sugar has been trending in the 300 to 400's over the last 2 weeks. At one point, he had a blood sugar spike to either 500 or 600. He states that his last hemoglobin A1c was 6.7, which has been his average for approximately 2 years. The patient checks his blood sugar 2 to 3 times per day and rarely has a blood sugar that goes over 200. He explains that he used to be on an insulin pump and had an A1c that at one point was 13. He states that he worked with an endocrinologist to get it down to where it is now.

MEDICAL HISTORY

The patient reports a history of diabetic neuropathy.

SOCIAL HISTORY

The patient enjoys hiking.

REVIEW OF SYSTEMS

Constitutional: Reports subjective fever and chills
Respiratory: Reports cough and shortness of breath with ambulation.
Gastrointestinal: Denies nausea and vomiting.
Musculoskeletal: Reports right foot pain and right calf cramping.
Skin: Reports right foot ulcer with yellow foul smelling drainage, and red streaking coming up the front part of his ankle along the inside portion of his calf muscle.

VITALS

Temperature is slightly elevated.
Vitals are otherwise good.

PHYSICAL EXAM

CV: Edema and pain in calf. Bilateral palpable femoral and papiteal pulses are present. I do not recognize a palpable dorsalis pedis or posterior tibial pulse; however, they are present via Doppler.
MSK: Examination of the right foot: The necrotic wound on his heel is present. It is approximately 2 cm x 2 cm. I do recognize the sloughing of the tissue, as well as what looks like cellulitis around the area, and erythema. An odor is present from the wound. I do not appreciate any bony exposure now. No pain to palpation in the effected area.

RESULTS

3 views of the right foot were taken today. These reveal no evidence of osteomyelitis or infection.

ASSESSMENT

Right non-healing diabetic foot ulcer.
Diabetes.

PLAN

After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed.

In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results.

INSTRUCTIONS

The patient will follow up with me in 7 days to check on his progress."
aci,D2N087,"[doctor] hi richard how are you the medical assistant told me that you have a tick bite is that what happened
[patient] i really do n't know where i got it but i i had i do get out in the woods and i do spend a lot of time out in the yard but yeah i've got a tick bite around my knee and and it's been it's been over a week and and just it just burns and just quite annoying
[doctor] okay and have you had any fever or chills
[patient] i have not at this point it just feels warm on that spot
[doctor] okay alright and have you noticed any other joint pain like in your elbows or shoulders or anything like that that since this started
[patient] nothing other than my typical arthritic pain
[doctor] okay alright now you say that you like to go outside and and you're working in the yard now i i heard that you were a a hunter when was the last time you went hunting has hunting season started yet i do n't even know
[patient] well i i did go hunting not long ago couple of weeks ago
[doctor] okay did you did you
[patient] windle season is open well it it's actually on a on a a got the right word for it but it it's where they train dogs and things like that
[doctor] okay
[patient] type thing
[doctor] okay did you i did did did were you able to shoot anything did you bring anything home
[patient] well actually i yeah i shut several i had some grandchildren with me so i let them have what they wanted
[doctor] nice nice you know i i did hear i do n't know much about hunting but i did hear a hunting software joke the other day do you want to hear it
[patient] sure
[doctor] so what software do hunters use for designing and hunting their pray
[patient] man i have no idea
[doctor] the adobee illustrator get it
[patient] do n't be
[doctor] anyway i die grass let's just get back to our visit here so about your line or about your tick bite so do you notice that it's hard for you to move your knee at all
[patient] not at this time no
[doctor] no and do you have any problems walking
[patient] no
[doctor] no okay and have you ever had a tick bite before
[patient] i have when i was younger i used to get a lot of them because i spent a lot of time out of the woods never get into anesthesia takes you can get several bites out of that but this was just one
[doctor] okay alright and have you ever been diagnosed with what we call lyme disease before
[patient] i have not
[doctor] you have not
[patient] i would n't know so i would n't know what symptoms are
[doctor] okay
[patient] what you just asked me i guess maybe
[doctor] yeah so some of those symptoms like any flu like symptoms have you had like any body aches or chills or anything like that
[patient] no just really just kind of a a headache just generally do n't feel well
[doctor] generally do n't feel well okay and has that been since the tick bite
[patient] it has
[doctor] it has okay alright and any other symptoms like a cough or shortness of breath or dizziness or anything like that
[patient] no
[doctor] okay now since you are here let me just ask you a little bit about your high blood pressure did you buy the blood pressure cuff i asked you to have you been checking your blood pressure at home
[patient] periodically yes
[doctor] okay and do you think that they are running okay
[patient] yeah blood pressure seems to be doing okay the lisinopril works well
[doctor] good i was just gon na ask you if you were taking your lisinopril so that's good okay and any side effects from the lisinopril since we started it i think we started it about a year ago two years ago
[patient] no no no side effects that i'm aware of
[doctor] no side effects okay and then in terms of your diabetes are you watching your sugar intake
[patient] yeah i usually watch it the form of high what i'm eating but
[doctor] i am a big pie fan as well i know what's your favorite type of pie
[patient] well you know it's favorite boy i just like pie you know apples cherry chocolate you know bicon
[doctor] yeah
[patient] i try to try to avoid the bicon because i think it's just all sugar but i do like it
[doctor] okay
[patient] less
[doctor] i like it too alright are you taking the metformin twice a day
[patient] not everyday but most of the time
[doctor] okay alright and are you checking your blood sugars pretty regularly
[patient] i try to
[doctor] okay and do you do you know on average how they're running are they running below like one fifty or
[patient] yeah it's definitely running below that
[doctor] okay your blood sugars are running below
[patient] it's it's probably with with with the metformin it seems to be you know one twenty
[doctor] good
[patient] pretty regular
[doctor] good your blood sugars are running in the one twenties that's really good okay alright well i wan na just go ahead and do a quick physical exam okay so i'm looking here at your vital signs and your vital signs look really good i do think you're doing a good job with taking your lisinopril your blood pressure's about one twenty two over seventy right now which is right where we want it your heart rate is nice and slow at sixty seven again which is right where we want it and i do n't appreciate any fever today you you have a normal temperature at ninety eight . four which is really good so i'm just gon na be going ahead and calling out some physical exam findings and i'm gon na let you know what that means when i'm done okay so on your heart exam your heart is in a nice regular rate and rhythm i do n't appreciate any murmur rub or gallop on your lung exam your lungs are nice and clear to auscultation bilaterally on your right knee exam i do appreciate some erythema and edema as well as an area of fluctuance over your right patella now does it hurt when i press
[patient] it's a little bit sore
[doctor] okay there is pain to palpation of the right anterior knee and i'm just gon na bend your knee up and down does that hurt at all
[patient] no no it's just more of the typical grinding that i would feel
[doctor] okay there is full range of motion of the right knee and on skin examination there is evidence of a bull's-eye rash over the right knee okay so what does that mean richard so that means that you know you do have some area of some inflammation over the over the right knee where you where you have that tick bite and you do have what we call that bull's eye rash which is what we get concerned about with with lyme disease so let's just talk a little bit about you know my assessment and my plan for you okay so for this first problem of your of your tick bite my concern is that you might have lyme disease based on the presentation of your right knee so i'm gon na go ahead and start you on doxycycline one hundred milligrams twice a day
[patient] we're gon na continue that for about three weeks i'm also gon na go ahead and send a lyme titer as well as a western blot to see if you do in fact have lyme lyme disease and we'll have to go ahead and just see how you do with this we you know i'd like to avoid intravenous antibiotics which i think we can avoid but i wanted to see how you do so
[doctor] do you have any questions about that
[patient] yeah i did n't know what those last two things or just
[doctor] yeah so so we are gon na start you on some antibiotics to help help you with this
[patient] you know possible lyme disease and i'm gon na just order some blood tests just to see exactly what's going on and then you know sometimes people need intravenous antibiotics because lyme disease can cause problems on other organs like your heart that type of thing
[doctor] if not treated appropriately and sometimes we need to give antibiotics through the iv which i'd like to avoid i think that we got this early enough that we can just treat you with some oral antibiotics okay for your second problem of your hypertension you know i think you're doing a really good job let's go ahead and continue you on the lisinopril twenty milligrams once a day and i wan na just go ahead and order a lipid panel just to make sure that everything is okay with your cholesterol how does that sound
[patient] that's fine
[doctor] great and then for your third problem of your diabetes i wan na just go ahead and order a hemoglobin a1c and continue you on the metformin one thousand milligrams twice a day it sounds like you're doing a good job since your blood sugars are running in the one twenties i do n't think we need to make any adjustments but we'll see what the hemoglobin a1c shows that gives us a an idea of what your blood sugars are doing on a long-term basis how does that sound
[patient] okay at what point time do you start kinda checking kidney function i've been told that metformin can possibly cause some kidney issues
[doctor] so it can you know your kidney function we've you know i think you've been really lucky it's been normal i checked it about two months ago and it looks pretty good it looks pretty normal but since we're doing blood work on you i can go ahead and order a a basic metabolic panel just to make sure that your kidney function is stable
[patient] okay that'd be good
[doctor] okay anything else
[patient] not that i can think of at this time as soon as i leave
[doctor] well you know where to find me okay
[patient] alright
[doctor] take care bye","CHIEF COMPLAINT

Tick bite.

MEDICAL HISTORY

Patient reports a history of arthritis, hypertension, and diabetes type 2.

SOCIAL HISTORY

Patient reports he enjoys spending time outside in the woods and working in the yard. He went hunting with his grandchildren a couple of weeks ago.

MEDICATIONS

Patient reports taking lisinopril 20 mg once a day and metformin 1000 mg twice daily most of the time.

REVIEW OF SYSTEMS

Constitutional: Reports general ill feelings. Denies any fever, chills, flu like symptoms, body aches, or trouble waking.
Respiratory: Denies cough or shortness of breath.
Musculoskeletal: Denies joint pain or problems with ambulation.
Skin: Reports warmth on the right knee.
Neurological: Reports headache. Denies dizziness.

VITALS

Blood Pressure: 122/70 mmHg.
Heart Rate: 67 beats per minute.
Body Temperature: 98.4 degrees F.

PHYSICAL EXAM

Neck
- General Examination: Neck is supple without thyromegaly or lymphadenopathy.

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.

Musculoskeletal
- Examination of the right knee: Erythema and edema as well as an area of fluctuance noted over the right patella. There is pain to palpation of the right anterior knee. Full range of motion.

Integumentary
- Examination: There is evidence of a bull’s eye rash over the right knee.

RESULTS

Patient's previous kidney function is within normal limits.

ASSESSMENT AND PLAN

1. Tick bite.
- Medical Reasoning: My concern is that he might have Lyme disease based on the presentation of his right knee.
- Patient Education and Counseling: The patient and I discussed blood testing to determine if he does in fact have Lyme disease. I explained that Lyme disease can cause problems with other organs if not treated appropriately. We discussed that sometimes antibiotics need to be administered intravenously if oral antibiotics are not given early enough. We will see how he does with a course of oral antibiotics as I would like to avoid intravenous antibiotics.
- Medical Treatment: Prescription for doxycycline 100 mg twice a day for 3 weeks provided. Lyme titer and Western blot will be obtained to determine if he has Lyme disease.

2. Hypertension.
- Medical Reasoning: This is well-controlled at this time.
- Patient Education and Counseling: The patient and I discussed that he is doing really well monitoring his blood pressure at home.
- Medical Treatment: Continue lisinopril 20 mg once a day. Lipid panel ordered to assess his cholesterol levels.

3. Diabetes type 2.
- Medical Reasoning: He is doing a good job managing his diabetes since his blood sugars are running in the 120s. I do not think we need to make any adjustments, but we will see what the hemoglobin A1c shows as that gives us an idea of what his blood sugars are doing on a long-term basis.
- Patient Education and Counseling: We discussed that metformin can affect kidney function; however, his kidney function was last checked 2 months ago, and it has remained within normal limits.
- Medical Treatment: Continue metformin 1000 mg twice a day. Hemoglobin A1c ordered. Basic metabolic panel ordered to assess kidney function. 

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