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[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 .

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. "

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] so sophia i see that you you hurt your knee tell me about what happened [patient] yeah i was jumping on my kid's trampoline and i could just slipped out from under me [doctor] my gosh one of those big trampolines in your back yard [patient] yeah a pretty big one [doctor] okay which knee was it [patient] my right knee [doctor] right knee okay and when did this happen [patient] about four days ago [doctor] great the weather was perfect this weekend so i'm glad you at least got outside sorry to hear you got hurt okay so your right knee did you did you feel it like pop or or snap or anything when you hurt it [patient] yeah i felt a little pop and then it swelled up really big afterward [doctor] okay did you try anything for the pain [patient] i took some ibuprofen and i put some ice on it [doctor] okay did that help [patient] a little bit but it's still really hard to get around [doctor] alright and have you have you been able to stand on it or does that hurt too much [patient] it hurts quite a bit to stand but i am able to put weight on it [doctor] okay alright and what part of the knee is it inside outside middle [patient] kind of that inside part of my kneecap [doctor] okay alright and okay so as long as you're here and then your primary care physician i'm looking through your chart and it looks like we're treating your diabetes so how you've been doing with your your diet overall are you are you keeping your sugars low [patient] it's going okay i i forget to check quite a bit though [doctor] sure [patient] on it [doctor] yeah i understand how has your diet been lately [patient] it's been pretty good [doctor] okay okay good good you know it's hard to stay away from the sugary foods sometimes i i enjoy ice cream regularly okay so let's do physical exam as long as you are here so i'm just gon na listen to your heart your heart sounds normal no murmurs or gallops listen to your lungs quick if you can take a deep breath lungs are clear that's good news let's take a look at that knee right knee looks like it definitely has some swelling i'm gon na do some maneuvers here does it hurt when i push you on the inside of the knee [patient] yeah that hurts [doctor] okay how about the outside [patient] a little bit but not as much [doctor] okay so some pain on palpation on the inside little bit of pain on the outside of the knee if i bend the knee back does that hurt [patient] yeah [doctor] how about when i extend it [patient] yeah that hurts [doctor] okay so little bit of limited range of motion as well as pain on both flexion and extension on the knee i'm gon na push on this a little bit looks like your mcmurray's test is negative just checking for a meniscus tear okay so let's talk a little bit about your plan what i am concerned about for your knee is it sounds like you have a torn or injured mcl i it's that inside tendon in your knee so i'm concerned about that since you're having trouble with weightbearing and you heard that pop so what i'm gon na do is i'm gon na put you in a straight leg brace and i'll prescribe some mobic you can start taking that as a a pain reliever and to try to get some of the swelling down i want you to ice your knee once an hour for about fifteen minutes but i'm also gon na send you out for an mri because we wan na make sure this is what happens see if there's any other damage to the knee does that sound good [patient] yeah that sounds great thank you [doctor] yeah and then for your diabetes as long as you're here it sounds like you're managing that pretty well but i do wan na get a recheck on your hemoglobin a1c and then i'm also i'm going to get a refill on the metformin that you have been taking five hundred milligrams so you can keep taking that as well so do you have any other questions for me [patient] no that's it thanks [doctor] alright well thank you hope that you feel better

ASSESSMENT AND PLAN 1. Right knee pain. - Medical Reasoning: I am concerned about a torn MCL due to pain on ambulation and trouble with weightbearing, as well as the pop she heard. - Patient Education and Counseling: We discussed treatment options today including bracing, anti-inflammatories, and icing. - Medical Treatment: I am going to put her in a straight leg brace and I will prescribe some Mobic. She can start taking that as a pain reliever and to try to get some of the swelling down. I want her to ice her knee once an hour for about 15 minutes. - Additional Testing: I am also going to send her out for an MRI. 2. Type 2 diabetes. - Medical Reasoning: The patient states that her type 2 diabetes are well-managed. - Medical Treatment: I am also going to get a refill on the metformin that she has been taking 500 mg. - Additional Testing: We are going to recheck her hemoglobin A1c.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[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

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."

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hi , john , how are you doing ? [patient] hi , good to see you . [doctor] good to see you too . so i know the nurse told you about dax , i'd like to tell dax a little about you . [patient] sure . [doctor] so john is a 55-year-old male with a past medical history significant for anxiety and epilepsy who presents with an abnormal lab finding . so , john , um , i , uh , was notified by the emergency room that you , um , had a really high blood sugar and you were in there with , uh ... they had to treat you for that , what was going on ? [patient] yeah , we've been going from place to place for different events and we've had a lot of visitors over the last couple of weeks and i just was n't monitoring my sugar intake and , uh , a little too much stress and strain i think over the last couple of weeks . [doctor] okay , yeah , i had gone through your hemoglobin a1c's and you know , they were borderline in the past but- [patient] mm-hmm [doctor] -i guess , you know , i guess they're high now so how are you feeling since then ? [patient] so far so good . [doctor] okay , did they put you on medication ? [patient] uh , they actually did . [doctor] okay , all right . i think they have here metformin ? [patient] yeah , that's- that sounds right . [doctor] all right , um , and , um , in terms of your anxiety , i'm sure that this did n't help much- [patient] did n't help , no , not at all . [doctor] how are you doing with that ? [patient] um , i had my moments but , um , it ... now that it's almost the weekend , it's- it's been a little bit better . i think things are under control by now . [patient] okay . [doctor] okay ? um , how about your epilepsy , any seizures recently ? [patient] not in a while , it's been actually quite a few months and it was something minor but noth- nothing major ever since . [doctor] okay . all right , well you know i wanted to just go ahead and do , um , a quick review of the systems , i know you did a cheat with the nurse- [patient] mm-hmm . [doctor] any chest pain , shortness of breath , nausea , vomiting , dizzy- dizziness ? [patient] no , no . [doctor] okay , any recent fever , chills ? [patient] no . [doctor] okay . and all right , let's go ahead do a quick physical exam . hey , dragon , show me the vitals . so looking here at your vital signs today , um , they look really good . so i'm just gon na go ahead and take a listen to your heart and lungs . [patient] mm-hmm . [doctor] okay , so on physical examination , you know , everything seems to look really good , um lungs are nice and clear , your heart's at a regular rate and rhythm . you do have some trace pitting edema to your lower extremities so what that means is that it looks like you might be retaining a little bit of fluid- [patient] mm-hmm . [doctor] um , did they give you a lot of fluid in the emergency room ? [patient] they actually did . [doctor] okay , all right , so it might just be from that . okay , well let's look at some of your results . hey , dragon , show me the glucose . okay , so yeah , you know i know that they just checked your blood sugar now and it was 162 and you know , what ... you know , did you eat before this ? [patient] uh , probably about two hours ago . [doctor] okay , all right . hey , dragon , show me the diabetes labs . yeah , so your hemoglobin a1c here is is 8 , you know last time we had seen it , it was about 6 and we had n't put you on medications so , um , i think it's something we'll have to talk about , okay ? [patient] you got it . [doctor] um , so let's just talk a little bit about my assessment and my plan for you so for your first problem , this newly diagnosed diabetes . um , you know , i want to continue on the metformin 500 mg twice a day . we'll probably increase that over time . [patient] mm-hmm . [doctor] i'm gon na go ahead and order hemoglobin a1c for the future okay ? [patient] sure . [doctor] um for your second problem , your anxiety . it sounds like you know you might have , you know , some issues leading into the winter . how do you feel about that ? [patient] well , i'll try something new just to help . if it helps that'd be great . [doctor] okay , all right , and so for your last ish issue , your- your epilepsy , you know , i think you saw your neurologist about three months ago , you must be due to see her again some time soon ? [patient] i am . [doctor] and we'll just continue you on the keppra , okay ? [patient] sure . [doctor] any questions ? [patient] not at this point , no . [doctor] okay , um , hey , dragon , finalize the note .

ASSESSMENT AND PLAN John Brooks is a 55-year-old male with a past medical history significant for anxiety and epilepsy. He presents today with an abnormal lab finding. Newly diagnosed diabetes. • Medical Reasoning: His past hemoglobin A1c levels have been borderline high, but his most recent level was 8. His blood glucose level is also elevated in clinic today. • Additional Testing: Repeat hemoglobin A1c. • Medical Treatment: Continue metformin 500 mg twice daily. Epilepsy. • Medical Reasoning: He saw his neurologist about 3 months ago and has been asymptomatic for the past few months. • Medical Treatment: Continue Keppra at current dosage.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] elizabeth , how are you ? [patient] i'm doing okay . how are you ? [doctor] doing okay . so i know the nurse told you about dax . i'd like to tell dax a little bit about you , okay ? [patient] okay . [doctor] all right . elizabeth is a 66-year-old female with a past medical history of significant for depression and hypertension who presents for her annual exam . so elizabeth , it's been a year since i've seen you . [patient] mm-hmm . [doctor] how are you doing ? [patient] i'm doing well . there's been so many events now that we've been able to get vaccinated , i've been able to see my grandkids again , go to more birthday parties , it's been fantastic . [doctor] yeah , i know . i've ... i mean , we've had some communication over telehealth and that type of thing , but it's not the same as being in-person , so i'm happy to see you today . now tell me a little bit about , you know , we have n't really got a chance to talk about your depression . how are you ... how are you doing with that ? i know we have n't had you on medication in the past because you're on medication for other things . what are your strategies with dealing with it ? [patient] so i've been going to therapy once a week for the past year . um , mostly virtually , um , but starting to get in-person . virtual was a bit of a struggle , but i feel like being in-person with someone really helps me . [doctor] okay . and do y- do you have a good support system at home ? [patient] yes , i do . i have my husband and , uh , my kids are right down the street from me , so i'm very lucky . [doctor] okay . all right . so that's good to hear . [doctor] how about your blood pressure ? did you buy the blood pressure cuff that i- [patient] yes . [doctor] . told you to ? okay . i know that we've been in communication and your blood pressures have been running okay . the last time i spoke with you , how are they doing since we last spoke ? [patient] they've been doing well . i've been using the cuff , um , once a day , and they seem pretty normal . [doctor] okay . and are you taking the lisinopril that i prescribed ? [patient] yes . [doctor] okay . great . all right . so i know that you did a review of systems sheet with the nurse when you checked in . you know , i know that you were talking about some nasal congestion . do you have any other symptoms , chest pain , shortness of breath , abdominal pain , nausea or vomiting , anything like that ? [patient] no . [doctor] no ? okay . all right . well , i wan na go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] hey , dragon , show me the vital signs . so here in the office , you know , your blood pressure looks really good , as does your heart rate . so you are doing a good job managing your blood pressure . so i'm gon na take a listen to your heart and lungs , okay ? [patient] okay . [doctor] okay . so on physical examination , i do n't appreciate any carotid bruits in your neck . on your heart exam i do notice a slight 2/6 systolic ejection murmur , which we've heard in the past , so i think that's stable . your lungs in- are nice and clear , and you have some trace lower extremity edema bilaterally , so all that means is , you know , i agree , you know , maybe we should watch your diet a little bit better , okay ? but i wan na take a look at some of your results , okay ? [patient] okay . [doctor] all right . hey , dragon , show me the ekg . and the nurses did an ekg before you came in , and that looks perfectly fine , okay ? so i wan na just go ahead and talk a little about your assessment and my plan for you . so for your first problem , your depression , i think you're doing a really good job with your strategies . i do n't think ... it does n't sound to me like i need to start you on any medication at this time , unless you feel differently . [patient] no , i'm , i'm , good in that department . [doctor] for your second problem , your high blood pressure , i agree , everything looks fine here now . i wan na just continue on the lisinopril , 20 milligrams a day . and i want you to continue to watch your blood pressures as well , and if they start rising , i want you to contact me , okay ? [patient] okay . [doctor] and for your third problem , for an annual exam maintenance , you know , you're due for a mammogram , so we'll go ahead and schedule that , okay ? [patient] all right . [doctor] all right . do you have any questions ? [patient] um , can i take all my medicine at the same time ? does it matter ? [doctor] yeah . you can set an alarm so that it reminds you to take your medication . but yeah , you can , you can take them altogether . [patient] okay . [doctor] all right . hey , dragon , finalize the note .

ASSESSMENT AND PLAN Elizabeth Peterson is a 66-year-old female with a past medical history significant for depression and hypertension. She presents today for her annual exam. Depression. • Medical Reasoning: She is doing well with weekly therapy. She also has a solid support system at home. • Medical Treatment: Continue with therapy and current management strategies. We will defer medication at this time. Hypertension. • Medical Reasoning: This is well controlled based on daily home monitoring. She has been compliant with lisinopril. • Medical Treatment: Continue lisinopril 20 mg daily. • Patient Education and Counseling: I advised her to continue with daily home monitoring of her blood pressures. She will contact me via the patient portal for any elevation in these readings. Healthcare maintenance. • Medical Reasoning: She is due for her annual mammogram. • Additional Testing: We will order a mammogram for her.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hey gregory good to see you today so take a look at my notes and i see that you're here you've had a nonhealing foot ulcer so can you tell me how you're doing how long have you had it what's going on with it [patient] sure so i've had it for about two months now and it's recently become red and is draining so i was concerned about how it's healed [doctor] okay and when you when you got it would you have any trauma to your foot or it just just did it pop up all of a sudden [patient] i think i may have gotten it from walking barefoot on the beach [doctor] okay alright and i saw you you did see your pcp before you came in did they put you on antibiotics [patient] they did start me on some medication but i did n't i did n't pick them up from the pharmacy yet [doctor] okay do you know which ones that they prescribed for you [patient] i do n't recall the name exactly [doctor] do n't recall alright [patient] something i had taken it before [doctor] okay so when you what beach did you go to when you you hurt it [patient] i'm sorry [doctor] so i was asking which beach did you did you go to when you hurt your foot [patient] at i was at dewey beach in my ambulance [doctor] dewey beach wow that sounds like fun i wish i could be a mab right now but all or as lucky as i guess as you are to go to dewey beach okay so does it hurt [patient] it sometimes it throbs does n't i do n't have specific pain but sometimes it does feel like there is some throbbing going on and again my my biggest concern is the it started to drain and it looks a little red [doctor] okay [patient] i have n't had that before [doctor] okay and that makes sense alright so as far as your diabetes you know and i think that's probably a a major cause of this not being able to heal how well are how well is that controlled [patient] i take my medication but i do n't check my sugar all the time [doctor] okay do you [patient] i'm not really sure how [doctor] okay do you know what your last a1c is i'm pretty sure you doc talk to you about it [patient] i think they told me it was around ten [doctor] around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look normal you do n't have a fever so let me just take a look at your foot so on your foot exam there is a one by two inch circular wound on the dorsal aspect of the lateral right foot so it's just proximal to the fifth mtp joint there is some redness some drainage present you have some edema around it there is fluid like you said that's coming out of it i do n't see any necrosis you do n't have any odor and i do n't appreciate any bony exposure so it pretty much is like you said it's it's red it's swollen i think you have an infection in there as well so when i touch it does that hurt [patient] no i i feel like increased pressure but it's not distinct [doctor] okay alright that's good so before you came in we did get an x-ray of your right foot and there is no evidence of osteomyelitis that means that luckily you do n't have a bone infection so that's great i think it's just in your skin so let's talk a little bit about your assessment and plan so you do have that diabetic foot ulcer and what i wan na do is i wan na order an abi ankle brachial index just to determine the blood supply in your foot to see if we can actually heal that ulcer i'm gon na also perform a debridement here just to take off some of that dead tissue and then i'm gon na prescribe you some clindamycin you can do that four hundred milligrams you take that for seven days take that twice a day just to try to get rid of that infection which you currently do have and that will get rid of some of that that redness and and drainage that that's happening right now did your doc did your pcp give you a surgical shoe something that you would wear while this is happening [patient] they did n't they mentioned that you may be able to give it to me [doctor] okay yeah we could definitely get you a a shoe because if you wear your regular shoes that pressure on that foot can really irritate it and take you backwards so i'll get you a shoe where you can wear that for the next month you know we just wan na make sure that it does heal and then i wan na see you back again in two weeks and we can we'll possibly do another debridement at that time we'll just take a look and see how the tissue is doing so how does that sound [patient] that sounds great [doctor] alright do you have any other question [patient] i do if anything happens in between [doctor] please feel free to call the office yeah please feel free to call you call the office we can definitely get you in you know if you are having any other issues and if it's an emergency if you feel like you're getting a fever feeling well please go to the urgent care or the er if you feel getting black or anything like that but otherwise we'll see you back in two weeks [patient] okay sounds great thanks document [doctor] alright great

ASSESSMENT Right diabetic foot ulcer. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that his x-rays did not reveal any evidence of osteomyelitis. I have recommended that we obtain an ankle brachial index to determine the blood supply in his foot. Debridement will be performed. A prescription for clindamycin 400 mg 2 times per day for 7 days will be provided as he does seem to have an infection. He will also be placed in a surgical shoe to provide increased support for the next month.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hey dylan what's going on so i lift quite a bit of weights i try to stay in shape as much as i can i'm not like normal people i lift heavy weights and my elbow is extremely sore which elbow is it [patient] actually it's both my elbows but my right elbow is hurting me the most [doctor] okay and you said you lift a lot of weights [patient] mm-hmm [doctor] did you play any sports when you were younger [patient] no anything you can think of primarily it was basketball baseball and football [doctor] okay and did your elbows hurt at that time or is this a a new injury [patient] it's new [doctor] when did it start [patient] probably year and a half ago [doctor] okay on both elbows about a year and a half ago [patient] yeah [doctor] okay have you taken anything for the pain [patient] ibuprofen eight hundred milligrams three times a day [doctor] okay and does anything make it better or worse [patient] the more i use my hands or my arms the more it hurts [doctor] okay have you tried icing [patient] yes [doctor] does that give you any relief [patient] no [doctor] alright is it the inside or outside of your elbows [patient] inside [doctor] inside okay let's just do a quick physical exam here i'll take a look at your right elbow first [patient] mm-hmm [doctor] if i bend it this way up does it hurt it's your left does that hurt [patient] yes [doctor] how about this [patient] yes [doctor] okay so pain with both flexion and extension [patient] mm-hmm [doctor] looks like you have little bit of limited range of motion on extension not on flexion though you said it hurts right here on the inside of your elbow [patient] yes [doctor] okay so pain on the medial side with palpation [patient] yes [doctor] alright how about the outside [patient] no [doctor] no pain with palpation outside of the elbow you have do you have normal sensation in your fingers [patient] i think so [doctor] yeah [patient] yeah [doctor] okay great [patient] good to go [doctor] sensation is normal to the touch [patient] yes [doctor] pulses equal in all extremities how about the left elbow same thing if i bend it this way does that hurt [patient] not as much [doctor] how about this way [patient] not as much [doctor] alright so little bit of pain on flexion and extension little bit of limited range of motion on extension of the arm how about if you twist like you're opening a door [patient] yes [doctor] okay so some pain with torsion and twisting supination what about pronation [patient] no [doctor] no pain with pronation on the right side [patient] mm-hmm [doctor] same thing on the left [patient] yes [doctor] pain with supination no pain with pronation [patient] correct [doctor] alright so dylan it took some x-rays coming in looks like you do n't have any any fractures or any bony misalignment which i expect with this kind of injury i do think that what you have is medial epicondylitis which is [patient] is that golfer's elbow [doctor] yes same thing have you been golfing a lot [patient] well not in the past year and a half i've had this for a long time [doctor] okay also known as pictures elbow [patient] well i have n't been pitching either [doctor] hmmm well in any case what i'm gon na have to do is i'm gon na send you up for mri to take another look at this [patient] mm-hmm [doctor] that will be our next step so we'll get you scheduled for the mri probably get you in pretty quick here since we're a private practice [patient] thank god [doctor] yeah and once you get the mri i'll know a little bit more what i'd like to do is something called a whole blood transfusion have you heard of that before [patient] no please tell me remind me [doctor] yeah it should help with the healing of your elbow it's just a procedure we'll stick a needle in your elbow [patient] you do a stick needle in my elbow [doctor] mm-hmm and help with some of the healing of your elbow [patient] so it's kinda like dry needling then [doctor] no [patient] not at all [doctor] what is it [patient] is it is that that thing where like you take the blood out of like say my my thigh [doctor] mm-hmm [patient] and then you literally inject it into my tendon [doctor] yes [patient] that it activates the healing [doctor] yeah that's exactly what it is [patient] interesting cool [doctor] yeah [patient] maybe i have heard about that [doctor] we've we've had some really good responses from other patients on it so hopefully i mean that should be a good solution for you since you've been having issues with this [patient] i'm excited [doctor] yeah and we can hopefully get you scheduled for that in the next couple of weeks it's not not a major procedure and you should heal in the next two weeks so that wo n't be a problem especially considering that you're expecting a newborn soon we want to make sure you're all healed for that [patient] wow i did n't even say that [doctor] i read it in your chart [patient] man you doctors are good [doctor] yeah anything else going on today [patient] just trying to figure out how you're doing [doctor] very good thank you [patient] you're welcome [doctor] nice to see you [patient] you have a good day

ASSESSMENT Bilateral medial epicondylitis. PLAN After reviewing the patient's examination and radiographic findings today, we had a lengthy discussion in regards to his current symptoms. I want to get an MRI of the bilateral elbows for further evaluation. We discussed the possibility of performing a whole blood transfusion to encourage healing, and the patient is already familiar with this procedure."

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hi miss russell . [patient] hi- [doctor] nice to meet you- [patient] doctor gutierrez . how are you ? [doctor] i'm well . [patient] good . [doctor] hey dragon . i'm seeing miss russell . she's a 39-year-old female here for , what are you here for ? [patient] it's my right upper arm . it hurts really , really bad . [doctor] so severe right upper arm pain . [patient] yeah , uh yes . [doctor] and how did this happen ? [patient] i was playing volleyball yesterday , uh last night . um and i went to spike the ball , and the team we were playing , they're dirty . so um , somebody right across from me kinda kicked my legs from under me as i was going up , and i fell and landed on my arm . [doctor] mm-hmm , like right on your shoulder . [patient] yeah . [doctor] ow . [patient] yes . [doctor] that sounds like it hurt . [patient] it was nasty . [doctor] um , so this happened , what ? like 12 hours ago now ? [patient] uh , seven o'clock last night , so a little more than that . [doctor] okay . [patient] eighteen hours . [doctor] so less than a day . [patient] yeah . [doctor] in severe pain . [patient] yes . [doctor] have you taken anything for the pain ? [patient] i've been taking ibuprofen every six hours i think , but it's really not helping at all . [doctor] okay , what would you rate your pain ? [patient] it's like a nine . [doctor] nine out of 10 ? [patient] yeah . [doctor] so like really severe ? [patient] yes . [doctor] have you used any ice ? [patient] no , i have n't . [doctor] okay . and do you have any medical problems ? [patient] i have gallstones . [doctor] okay . do you take any medicine for it ? [patient] pepcid . [doctor] okay . and any surgeries in the past ? [patient] yes , i had a lumbar fusion about six years ago . [doctor] okay . [patient] um , yeah . [doctor] all right . let's uh , let's look at your x-ray . [doctor] hey dragon . show me the last radiograph . so this is looking at your right arm , and what i see is a proximal humerus fracture . so you kinda think of your humerus as a snow cone , and you knocked the- [patient] the top of the snow cone ? [doctor] the top off the snow cone . um , so i'll be gentle but i want to examine your arm . [patient] all right . [doctor] okay . [patient] all right . all right . [doctor] all right . are you able to straighten your arm ? [patient] yeah , i can just straighten the elbow as long as i do n't move up here . [doctor] as long as you do n't move your shoulder . [patient] yeah . [doctor] go ahead and bend . okay . so your exam is generally normal , meaning that the rest of your body is normal [patient] [doctor] but you've got some swelling and erythema- [patient] yeah . [doctor] . on that right shoulder . you've got uh , tenderness over your right shoulder . you've got normal pulses , and everything else is normal . any numbness or tingling in that right arm ? [patient] no . [doctor] okay . um , so what we're going to have to do- the good thing about um , these kinds of fractures is generally , they will heal up without surgery . um , but we have to put you in a sling that weighs your arm down and pulls it down . so we're going to put you in a long arm cast and a sling , and then we're gon na check you in two weeks to see if those bones have realigned and if they have n't , then we're gon na have to talk about doing surgery at that time . [patient] okay . [doctor] i'm going to prescribe you some pain medicine . we'll do lortab 500- lortab 5 milligram . [doctor] um , you can take one to two tablets every uh , six hours as needed for pain . i'll give you 20 of those . [patient] all right . [doctor] and um , do you have any allergies to medicines ? i did n't ask . [patient] no , i do n't have no allergies . [doctor] okay . um , hey dragon , go ahead and order any medications or procedures discussed . um , do you have any questions for me ? [patient] no , i do n't . [doctor] okay , great . why do n't you come with me , we'll get the tech to put the cast on . [patient] okay . [doctor] and we'll get you checked out . [patient] thank you . [doctor] hey dragon , finalize the report .

PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended we place her into a long arm cast and sling. She will follow up in 2 weeks for repeat imaging. At that point, we may need to discuss surigical options. I will prescribe Lortab, 5 mg, #20 (twenty) to take every 6 hours as needed for pain. All questions were answered. "

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hey anna good to see you today so i'm looking here in my notes says you have you're coming in today for some right ankle pain after a fall so can you tell me what happened how did you fall [patient] yeah so i was taking out the trash last night and i ended up slipping on a patch of ice like and then when i fell i heard this pop and it just hurts [doctor] okay so have you been able to walk on it at all or is it you know [patient] at first no like my friend who was visiting thankfully had to help me get into the house and i you know and now i'm able to put like a little bit of weight on it but i'm i i'm still limping [doctor] okay well you know that's not good we'll we'll hopefully we can get you fixed up here so how much how much pain have you been in on a scale of one to ten with ten being the worst pain you ever felt [patient] it's it's more like so when i first fell it was pretty bad but now it's it's at like a six you know like it's uncomfortable [doctor] okay and how would you describe that pain is it a constant pain or is it only when you move the ankle [patient] it's it's constant it's like a throbbing pain you know and like when i touch it it feels kinda warm [doctor] okay alright yeah but yeah i can feel it here so it does feel a little bit warm so i said you've been in a little bit of pain so have you taken anything for it [patient] well like last night i iced it and i kept it elevated you know i also took some ibuprofen last night and this morning [doctor] alright has the ibuprofen helped at all [patient] not really [doctor] okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before [patient] so you know in high school i used to play a lot of soccer but and and like i had other injuries but i've never injured like this particular ankle before but because i used to play like all the time i knew what i was supposed to do but this is i also knew that it was it was time to come in [doctor] okay yeah yeah definitely if you if you ca n't walk on it we definitely good thing that you came in today and we were able to see you so have you experienced any numbness in your foot at all [patient] no no numbness and i do n't think i've had like any tingling or anything like that [doctor] okay that that's good yeah it sounds like you have sensation there so yeah that that's really good so let me do a quick physical exam on you so i reviewed your vitals your blood pressure was one twenty over eighty which is good your heart rate your spo2 was ninety eight percent which is good that means you're you're getting all of your oxygen and so let me go ahead and look at your ankle real quick so when i press here does that hurt [patient] yeah [doctor] alright what about here [patient] yeah [doctor] okay so looking at your ankle and your right ankle exam on the skin there is ecchymosis so you have that bruising which you can see of the lateral [patient] malleolus [doctor] malleolus associated with swelling there is tenderness to palpation of the anterior laterally in the soft tissue there is no laxity on the anterior drawer and inversion stress there is no bony tenderness on palpation of the foot on your neurovascular exam of your right foot there your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch alright so we did get an x-ray of your ankle before you came in and luckily it's there is no fractures no bony abnormalities which is really good so let me talk a little bit about my assessment and plan for you so for your right ankle pain your symptoms your symptoms are consistent with a right ankle sprain have you sprained your ankle before most times people do the athletics play soccer it happens every so often but have you done that before [patient] no i do n't think so [doctor] okay well you're one of the lucky ones some of my my patients that play sports they sprain their ankle seems like every other week so good for you so for that that that ankle sprain i just want to keep i want you to keep your leg elevated when you're seated and i want you to continue to ice it you can ice it let's say five times a day for twenty minutes at a time just to help that swelling go down i'm gon na give you an air cast to help you stabilize the ankle so keep it from moving and then i'll give you crutches and so i want you to stay off that leg for about one to two days and then you can start walking on it as tolerated tolerated so how does that sound [patient] it's alright [doctor] alright so do you have any questions for me [patient] yeah like how long do you think it's gon na take for me to heal [doctor] i mean it should take a a couple of days i mean i think in a day or two you will be able to walk on it but still think it will be sore for the next couple of weeks you know your ankle sprain seems to be not the worst but it's kinda you know medium grade ankle sprain so as i would say about two to three weeks you should be back to normal you will see some of that bruising go away [patient] yeah okay can i get a doctor's note [doctor] no because you need to go back to work because you work on the computer not running so [patient] fine [doctor] yeah you ca n't get a doctor's note so if you if i write a note i'm gon na tell your boss that you have to go to work [patient] okay thanks [doctor] so i i would n't do that but yeah but otherwise if if if you continue to have pain after this week if you feel like it's not getting better please feel free to contact the office and we can get you back in and possibly do an mri if we you know need to [patient] okay [doctor] alright [patient] alright [doctor] anything else [patient] no that's it [doctor] alright thanks

ASSESSMENT Right ankle sprain. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regards to her current symptoms. I have explained to her that her symptoms are consistent with a right ankle sprain. I have recommended that we treat the patient conservatively. I have advised her to keep her right leg elevated when she is seated. I have also advised her to ice her right ankle 5 times per day for 20 minutes at a time to help with the swelling. I have also recommended that the patient be placed in an Aircast to stabilize the ankle. She will remain non-weight-bearing for 1 to 2 days, we provided her with crutches today, and then she can begin weight-bearing as tolerated.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

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

ASSESSMENT • Constipation • Mild hepatomegaly PLAN Patrick Allen is a 42-year-old male who presents for a new patient visit for chronic abdominal pain, constipation, and diarrhea. The most likely etiology of his abdominal pain is constipation given his history, exam with increased stool burden, and normal abdominal CT. Mild hepatomegaly was also noted on exam today and the patient reportedly had elevated liver enzymes on labs with his primary care provider 4 months ago. The patient is currently on Crestor which may be contributing to his elevated liver enzymes. We discussed findings, diagnosis, and next steps at length. Constipation • Start daily fiber supplement and increase water consumption to at least 48 ounces daily to help with bowel regularity. • Avoid trigger foods that may cause episodes of diarrhea. Mild Hepatomegaly • Repeat liver enzyme labs today. • Schedule a liver ultrasound pending lab results. • Encouraged to cease alcohol consumption. • Patient to contact his PCP to discuss alternative medications.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[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 .

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.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] okay so we are recording okay so okay so i understand you've so you've got a past medical history of type two diabetes and you're coming in and for evaluation of a newly diagnosed ovarian cancer so how are you doing today [patient] i do n't hear the question but i'm assuming that you when you say batcher so when i start talking about my dog and my three cats and all that those sort of things are not going to be included in the in the note [doctor] right i want you you can talk about those things yes [patient] okay [doctor] okay so with your newly diagnosed ovarian cancer so how are you feeling today how are you doing [patient] i'm doing pretty good depressed [doctor] little depressed i can understand it's a lot to take on is n't it [patient] yes [doctor] okay okay so lem me ask you some questions so what kind of symptoms were you having that prompted you your doctor to do the tests [patient] i was having severe pain and bleeding [doctor] okay now do you have other symptoms such as weight loss constipation vomiting or issues with urination [patient] no vomiting but constipation and weight loss [doctor] okay yeah that's understandable so do you have any children or have you ever been pregnant [patient] i'm sorry i did n't hear that part [doctor] do you have any children or have you ever been pregnant [patient] no to either one of those [doctor] okay so and do you know at what age you got your period and when you started menopause [patient] thirteen for my period and twenty eighth for menopause [doctor] okay do you take any oral hormone replacement therapy [patient] no [doctor] okay any history of endometriosis [patient] any history of what [doctor] endometriosis [patient] no [doctor] okay how about any family history of any gynecological cancers [patient] i was adopted [doctor] okay okay so i'm just gon na do a quick exam of your abdomen and then perform a vaginal exam okay [patient] okay [doctor] alright okay so i do feel the mass on the where to go here okay [patient] i did n't know you're gon na play a doctor today [doctor] i did okay okay so i do feel the mass on the left side but everything else looks good and on abdominal exam there is slight tenderness to palpation of the left lower quadrant no rebounding or guarding on vaginal exam there are no external lesions on the labia the vaginal vault is within normal limits the cervix is pink without lesions and on bimanual exam i appreciate a left adnexal mass and there is no masses on the right okay so now i reviewed the results of your abdominal ct which show a three centimeter left ovarian mass with an associated local localized lymph node involvement there is no evidence of gross peritoneal or metastatic disease so lem me tell you a little bit about my assessment and plan so for the first problem so i do think this is most likely ovarian cancer looking at your ct scan it looks like stage three a disease based on the lymph node involvement i want to start by sending off some blood tests like a ca-125 and hcg and afp and ldh these are just tests that help me to determine what type of tumor i'm dealing with and then i want you to undergo genetic counseling and testing to see if you have a genetic predisposition for developing ovarian cancer so this stage of ovarian cancer is treated by performing surgery followed by adjunct chemotherapy so this means we'll start chemotherapy after you've recovered from surgery okay so for the surgery i would perform a hysterectomy remove both ovaries and perform a lymph node dissection to remove the involved and involve lymph nodes as well as any other ones i see and i'll also send a sample of any tissue if there anything that looks suspicious at all and we'll be able to tell exactly what stage this is based on the pathology reports i then recommend chemotherapy with cisplatin and taxol and based on how the surgery goes i may want you to receive intraperitoneal intraperitoneal chemo which is done inserting a small tube into your belly for the chemo to go directly into your peritoneum now i know that was a lot sick in do you have any questions or [patient] am i gon na die [doctor] well that's a good question so based on what i see at this time i will we believe you have a favorable diagnosis prognosis and you're also still young and healthy which makes your prognosis even better and we do need to see a final pathology report to give you a definitive answer though okay [patient] alright alright

ASSESSMENT AND PLAN 1. Ovarian cancer. - Medical Reasoning: Looking at her abdominal CT results, it appears to be stage IIIA disease based on the lymph node involvement. - Patient Education and Counseling: I explained to the patient that the typical approach to treating this stage of cancer is surgical intervention followed by adjunct chemotherapy. The procedure and subsequent chemotherapy plans were discussed in detail. Given that she is young and otherwise healthy, I reassured her that I believe her prognosis is favorable based on her current status, however, this is dependent on the final pathology report. All of her questions were answered. - Medical Treatment: I want to start by ordering several blood tests including a CA-125, hCG, AFP, and LDH. I also want her to undergo genetic counseling and testing to see if she has a genetic predisposition for developing ovarian cancer. I recommend we perform a hysterectomy and oophorectomy, as well as a lymph node dissection to remove any involved lymph nodes. Any concerning tissue will be biopsied and sent to pathology for staging. After she has recovered from surgery, she will start chemotherapy treatment with cisplatin and Taxol. We may also consider intraperitoneal chemotherapy.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

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

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

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hi virginia how are you today what brings you in [patient] i'm doing alright i started seeing this new pcp last year and you know she has been doing a lot of changes to my medication and making sure everything is up to date and she my noticed that my blood pressure has been quite high so she added to medications but and but i you know i've been taking them i've been really good and i i before i was n't but now i am and we're still having a hard time controlling my blood pressure so she thought it would be a good idea for me to see you especially since she noted some on my last blood work she said something about my kidneys [doctor] okay yeah so okay let's before i dive into a lot of that tell me a little bit about how you've been feeling [patient] i would say you know most of the days i feel fine i'm still busy at work i definitely can tell though when my blood pressure is high [doctor] okay you measure it at home you you you measure your blood pressure at home [patient] yeah i she wanted me to get a blood pressure cuff so i did start getting checking my blood pressures probably like a few times a week [doctor] okay [patient] and so then i noticed that it has been getting higher the other day was even as high as one seventy over ninety [doctor] wow [patient] so i did call my pcp and she increased the meds again [doctor] yeah okay now i i just have a couple questions about that are you using a an electronic blood pressure recorder or do you have somebody help you at home [patient] yeah she i have a a electronic one an electronic arm one [doctor] okay okay yeah that's good that's good and have you ever tried do you go to cvs at all [patient] yeah i i do but i've noticed like since the pandemic i do n't see the blood pressures anymore [doctor] okay okay yeah i i thought the one down on main street they i thought they just brought that one back so [patient] did they [doctor] yeah [patient] that's good to know [doctor] you may wan na check that but okay so that's good but i what i'd like you to do with that is i'd like you to keep a record of them for me for my next visit with you so let's talk a little bit about your diet tell me how how is your diet what what are the what kind of foods do you like what do you eat normally [patient] alright do you want the honest answer [doctor] well yeah that would be better [patient] so i really you know with everything going on i really been trying to get better but i mean during football season it's really difficult i really love watching my games so have a lot of pizza wings subs like i said i've been trying to cut down especially on days where there is no games but it probably could be better [doctor] okay i think we all can say that but i do wan na just hey i do n't know that if you've tried it or not but there is a new restaurant down on fifth street and it is nothing but solids and i you know when i heard this i was like okay yeah it's just another these solids are absolutely amazing so if you ever get a chance yeah if you ever get a chance try try that i mean i think you would enjoy them because they're salads that they make are just out unbelievable so let me go ahead and i just have a few more questions and i'm gon na just ask these in in order and you just tell me and then we will come back and talk about them do you have any headaches [patient] really just when my blood pressure gets really high i have some mild headaches but otherwise i do n't have it on a regular basis [doctor] okay what about chest pain [patient] no chest pain [doctor] shortness of breath [patient] no shortness of breath [doctor] even with exertion [patient] even with exertion [doctor] okay do you have any swelling in your lower extremities at all that you noticed [patient] not if i'm on my feet for a long time i'll notice a little bit of swelling but otherwise no [doctor] okay and then a couple other family history questions anybody in the family have kidney disease or significant high blood pressure [patient] both my parents do have high blood pressure and one of them did have kidney disease [doctor] okay okay and in the the the form that you filled out when you came in it says that you are on ten milligrams of norvasc daily and carvedilol twenty five milligrams twice a day is those the medicines you're on [patient] yes i was also on lisinopril before but with the adjustments yeah those are the ones i'm on [doctor] okay and so here's where i think we are going to go do you take any nonsteroidals like advil or motrin or aleve [patient] yeah just once in a while for my like any knee pain or back pain that i have but again not like everyday [doctor] okay and then lastly what kind of alcohol intake do you have you know do you consider how many drinks a week is really what i'm looking for [patient] i'll have a couple of beers during the week and like one or two on the weekends [doctor] okay okay so lem me do a quick physical examination so i looked at your vitals when you came in today and your blood pressure it's still high it's one sixty nine over seventy four your heart rate was eighty eight and your oxygenation was ninety eight percent so those are all fairly good except that blood pressure's a little higher than we'd like to see now when i look at your neck i do n't see any jugular vein distention and i'm gon na listen here real quick no i do n't hear any carotid bruits i'm gon na listen to your lungs okay your lungs are clear and let me listen quickly to your heart i do hear that a two over six systolic ejection murmur and we'll we're gon na have to take a little bit look extra look at that that's when i i can hear an extra sound when i'm listening to your heart and you do have a small amount of one plus pitting edema bilaterally now i did so you do have that your diagnosis is uncontrolled hypertension you know and i think you're aware that that's what your your physician's been treating you for and most of the time this cause is is the cause of this is multifactorial it's not that there is just one thing causing it so we may need to be changing your medicine around and i'm gon na talk to your doctor but first thing before we make any more medication changes i want to order some tests first to rule out if there is any specific cause for this so first order will be a renal artery ultrasound and what i'm looking for there is that there is no areas of areas of narrowing in the the blood vessels of your kidneys that would be the cause of your hypertension in addition to that i'm gon na order a you get another urine collection some morning aldosterone levels reining levels and a twenty four hour urine and these things can really show me if there is any problems with your adrenal glands again this is a lot of big words but you know i'm i i'll write this all out for you i want you to decrease your alcohol i know you like those beers but let's bring it down to maybe one a week or two a week just to get those down lower and then your salt intake you need to be very judicious about decreasing that salt intake i'm gon na give you a referral to a nutritionist to discuss those changes for that you need and and they will help you get that cleared up and then finally stop taking any nonsteroidal medicines such as your advil or motrin the only thing i really want to want you taking is tylenol for any pain right now i am gon na prescribe one medicine and that's cardura four milligrams and i want you to take that once a day and that's good to see if that can help us with your blood pressure and then finally three weeks i'd like you to return i want you to record all of your blood pressures that you take over the next three weeks and bring them into the office but most importantly if you can try to take them at the same time everyday that would be beneficial for me any questions for me [patient] no i i just it's a lot so i i'm hoping this will work and this will get it under control [doctor] yeah i i think you know this will be you know this we're gon na spend some time together so i'm glad to have you as a patient but you know we got ta try to get this under control and i'm gon na i'll be talking to your pcp just to let them know that you know what my plans are and we'll stay real in sync on treating this as we move forward does that sound like a plan [patient] that sounds good thank you [doctor] okay take care i'll talk to you later [patient] okay alright bye

ASSESSMENT AND PLAN 1. Hypertension, uncontrolled. - Medical Reasoning: The patient's elevated blood pressure is consistent with uncontrolled hypertension. - Patient Education and Counseling: We discussed the nature of the diagnosis and that this is typically multifactorial. I advised the patient that further testing should reveal additional information. She was encouraged to reduce her intake of alcohol as well as her salt intake. I recommended that she stop taking anti-inflammatories and use Tylenol as needed for pain. We also discussed the importance of home blood pressure monitoring of the next 3 weeks to see if the medication is beneficial. - Medical Treatment: Renal artery ultrasound ordered. Urine collection, morning aldosterone levels, renal levels, and a 24-hour urine were also ordered. Referral to nutritionist provided. Prescription for Cardura 4 mg once a day provided as well.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] so bryan it's nice to see you again in the office today what's going on [patient] i was in my yard yesterday and i was raking leaves and i felt fine and then when i got into my house about two hours later my back started tightening up and i started getting pins and needles in my right foot [doctor] alright have you ever had this type of back pain before [patient] i had it once about three years ago but it went away after a day [doctor] okay and did you try anything for the pain yet did you take anything or have you have you tried icing [patient] put some ice on it and i tried two advils and it did n't help [doctor] okay does it get better when you're laying down sitting standing [patient] yeah i think the only thing that helped was a hot shower and it feels a little better when i sit [doctor] okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately [patient] i i i normally do n't do any physical activity [doctor] yeah i hear you i make a i make my husband do all the yard work too so alright let me take a look at that low back if if you bend over does that hurt [patient] it hurts a little bit when i bend over yes [doctor] okay how about when you stand back up [patient] no pain [doctor] okay so no pain on extension some pain on flexion how about when i push right here on your back [patient] yeah that hurts [doctor] okay so some pain to palpation right around the l5 can i have that [patient] what happens when family members chime in like i'm doing right now because i actually think it was it hurts more when he stands up because i've watched him bend over but it's when he stands up that it really hurts [doctor] okay and and what's your relationship [patient] partners [doctor] okay so your partner is here with you today and reports that he is also having pain when you are standing up [patient] i've spent so many times you know who i am [doctor] so that's right you always come in together have you noticed anything else partner when when he is [patient] i'm worried about it because he is you know his pain tolerance is so high and he would n't be saying anything if it really was n't a problem because it's not at all like last week when he thought about raking leaves but did n't actually rake leaves but then his back did n't hurt as much but this time it really hurts [doctor] okay so you think this is more of a long term injury [patient] no he was just thinking about it hurting when he thought about raking but it did n't [doctor] okay alright and have you noticed any any prior pain with with the back [patient] i do n't want to take this away you better go back to talking to him [doctor] that's alright let's see how it turns out okay so how about if you if i push down on both your feet like this can you push back up on my hands [patient] can you repeat that [doctor] if i'm pushing down on your feet can you push push your feet back [patient] i [doctor] alright so your dorsiflexion is normal looks like pulses are equal in all extremities you said you had a little bit of a tingling sensation in which leg [patient] that would be my right leg [doctor] okay so some tingling in your right leg alright so i know that you had an x-ray when you came in because we always do x-rays when we have our patients come in of your low back and everything looks normal from that perspective so for your back pain sounds like you probably sprained your low back so i what i want you to do is let's rest it i'm going to prescribe some meloxicam have you taken that before [patient] i have not taken meloxicam [doctor] alright so i'll prescribe that i'm also gon na prescribe some physical therapy i know you said you have n't been overly active and your partner reported the same thing for a long time so we might wan na get you into some pt and hopefully get you back back in shape get you some stretches that you can do and some exercises and then you know if it's not improving i want you to send me a message and we can possibly look into see if there is anything else going on potentially an mri if it's still not improving does that sound like an okay plan [patient] it sounds reasonable [doctor] alright [patient] i think he should have an mri now i think he had surgery yesterday i think he should have an mri now this it's been hurting for like six hours now and she had an mri we are really worried about it [doctor] alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving [patient] good answer [doctor] alright alright hope you feel better

ASSESSMENT Low back sprain. PLAN The examination findings and x-ray results were discussed with the patient and his partner today. I recommend we treat this conservatively with rest, meloxicam, and formal physical therapy. If he fails to improve, we can consider obtaining an MRI for further evaluation.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] patient is julia jones , date of birth 5/16/1996 . she is a new breast reduction consult . hello , how are you doing today ? i'm dr. gonzalez . it's nice to meet you . [patient] nice to meet you , ma'am . how are you ? [doctor] i'm doing good , thank you . so you're here to discuss a breast reduction , correct ? [patient] yes . that's right . [doctor] okay . perfect . let me just get logged in , here . have you met with anyone before about a breast reduction ? [patient] no , i have n't . [doctor] okay . and how long have you been considering this ? [patient] it's probably been about six or seven years . but i mean , it's always been in the back of my mind . [doctor] well , i perform a lot of breast reduction surgeries , pretty much every week , so it is a very common procedure . [patient] okay , that's reassuring . [doctor] yeah . so what i wan na do first is just get a little bit of history about the sort of symptoms that you're having . and then i'll do a quick exam . [patient] okay . that sounds good . [doctor] and then we'll talk more about the surgery and what it entails . and , um , at this point , who is your insurance provider ? [patient] i have blue cross blue shield . well , actually , my husband just accepted a new job , and i will be on his plan , uh , which i believe is not going to be blue cross , but it may be changing . [doctor] okay . what we typically do when we do a breast reduction consult , i'll document your symptoms , symptoms , we'll take some pictures , then , um , they get sent to the insurance company . and what they'll do is decide whether it's approved , or medically necessary , or not . but we wan na make sure we send it to the right insurance . do you know when you'll be on the new plan ? [patient] most likely july . [doctor] okay . so we may just wait until july to submit for approval at that time . [patient] okay . [doctor] so regarding your symptoms , do you experience back pain ? [patient] well , i've been going to the chiropractor for a few years . i do have a lotta pain here and here . but i do n't know if it's all from my breasts or not . it gets painful and builds up . so i think i could attribute it to my breasts , when i'm working at my desk all day . [doctor] okay . and in your neck and your upper back . and how long has this been going on ? would you say five years , 10 years , or even since puberty ? [patient] i would say since i was in high school . [doctor] okay . and do you have the bra strap indentations in your shoulders ? um , i saw that you're wearing about a g cup . [patient] yes . i do get indentations , but i do n't really wear a regular bra that often . i mostly were a 34 e sports bra because it's more comfortable . and the others are expensive in my size . [doctor] yeah , i have heard that as well . and , um , have you had any children , or are you planning to have any children in the future ? [patient] no , i do not have any kids now . but we might plan to in the future . [doctor] okay . and at this time , are you experiencing any numbness or tingling in the s- in the hands or any nipple pain ? [patient] sometimes , yes . [doctor] okay . and rashes , do you get any rashes underneath your breasts ? and , and it could be from sweating . [patient] no , but they are always sweaty . [doctor] okay . and then do you feel like your activities are limited because of the size ? [patient] there's certain things i do when i have to hold them , like working out and any jumping or running . and it hurts . [doctor] and it hurts , okay . and , and you saw a chiropractor . but what about physical therapy for your back pain ? or do you take any pain medicine for it ? [patient] y- no , but i do take a migraine medication , propranolol . [doctor] that's okay . so let's see . i know that you have a history of breast cancer in your family . have you had any mammograms ? and how old was your mother when she had it ? [patient] mom was 40 . and they recommended me starting at age 30 for mammogram . i'm still ... i mean , i'm 25 . so i'm still a little bit young . [doctor] okay . and otherwise , it seems like you're really healthy ? [patient] yes , for the most part . i lost about 10 pounds over the past few months , and i still would like to lose about 20 more pounds . [doctor] congratulations . that's great . and then , um- [patient] thank you . [doctor] . so then ... you're welcome . and so do you use any tobacco , drugs , or alcohol ? and then , um , you said that you were going to school . what are you going to school for ? [patient] uh , i drink a little wine on occasion , and for school , i'm currently studying psychology . [doctor] okay , that's great . all right . so what we'll do is we'll go ahead and take a look . i'm gon na take a couple of measurements . and we'll kinda talk about the surgery afterwards . um , so go ahead and stand up for me , julia . okay . so , looking at the measurements , it looks like one breast is a little lower than the other . [patient] yeah . [doctor] okay . well , thank you so much . it looks like i have all the measurements that we need . you can go ahead and cover up now . [patient] okay . [doctor] so i think you're a great candidate for a breast reduction . when we talk about a breast reduction , what happens is that we remove the tissue out of the breast . [patient] okay . that's fine . [doctor] and we would then lift them and elevate the nipple position in order to help with your back pain , neck pain , and because i'm a plastic surgeon , of course i want them to look nice as well . [patient] right . [doctor] so typically , when you do the breast reduction , we make an incision around the nipple straight down and then underneath . and it kinda looks like , um , an anchor below . then straight down , and underneath , and through that incision , we're able to f- to lift the breast . and we'll take off any extra fat and breash- breast tissue . so that way it becomes smaller in size . and i noticed that you would like to be a b cup . so i do tell every patient we can make you as small as your blood supply allows . and what that means is we must move the nipple without cutting off any of its blood supply during the surgery . [patient] okay . well , thank you for explaining that . [doctor] you're welcome . and in your case , you'll probably be a small c. um , a b cup might be a little bit small , but we'll see once i'm doing the , the procedure for you . [patient] okay . [doctor] and typically the surgery takes about three hours . you will have drains , one in each side . and that helps prevent fluid from building up in the breast . and that stays in for about a week . and then we'll remove them in the clinic . and you'll have a clear plastic tape over your incision that should help with the scars . and , um , we've seen that patients who have lighter skin , the scars will tend to be red at first . and then it takes about a year for a scar to mature in line . [patient] okay . well , i'm not too worried about the scars . [doctor] okay . and i do like to keep patients overnight . it's just going to be for one night in the hospital . and we just wan na make sure your pain is controlled , make sure you're not nauseated , all of that stuff . some patients wan na go home that same day . but you know that some people get nauseated , and the last thing that i want is for you to be vomiting at home alone without the , the support here at the facility . [patient] okay , yeah , that sounds good . [doctor] okay . and then about 30 % of patients say that they can not breastfeed after a breast reduction , and the reason is the breast is made up of fat . and it's also made up of a gland . and the gland is what produces the milk . [patient] okay . [doctor] and so in order to reduce the size of the breast , we have to take out both the fat and the glands . so it just depends on how much is left , whether you can breastfeed in the future . and then also , the breast will change over time . if you , um , gain weight , they will get larger , things like that . [patient] yeah , okay . [doctor] and if you have children , they will change as well . they will enlarge , especially if you can breastfeed . but they'll go back down and will appear , um , a little bit deflated . [patient] yeah . i do n't know if i'm interested in breastfeeding . [doctor] okay . um , the hormones of pregnancy , though , will change the breasts , so that's just something to be aware of , and i tell all younger patients that . [patient] okay , yeah . absolutely . [doctor] and then typically nipple sensation is fine after a breast reduction , but there is a slight chance that you'll have an alteration in the nipple sensation or not have any sensation in the nipple . generally the nipple is just fine unless it is a massive reduction . and it's quite normal after surgery to be a little bit bruised , and then it just takes some time for that to go away . [patient] yeah , okay . [doctor] but other than that , you know , most patients are very happy after the breast reduction because the symptoms of the back pain , the neck pain , you can feel relief almost immediately . so do you have any questions , julia , about the process or anything like that ? [patient] no , not really . [doctor] okay . and , i do think you're a good candidate for it . and i think you'll benefit from it as well . [patient] good . i look forward to a relief . [doctor] i think you just have to do it when you are ready , when you know that you feel like it's a good time , because it is a commitment , and you will have some activity restrictions for about six weeks after surgery , uh , no heavy lifting . and i do say no driving for two to three weeks . and the drains stay in , like i said , for about a week . [patient] okay . well , i am ready as soon as my insurance is switched over . [doctor] okay . well , i think from this point , if you want to , we can take photos today , while you're here . i have all the documentation now in the note about your symptoms , and that's what the insurance company is going to look for . so thank you for answering those questions . so once we have the new provider , we'll go ahead and get that submitted . and then , when they approve it , um , what the office will do , is they'll work with you on a surgery date , and then we'll meet again right before the surgery to answer any last minute questions and go over the instructions in more detail , things like that . [patient] okay . well , i will notify the office as soon as i have the insurance information . [doctor] that sounds great . and then we can get it all in process . and it was so nice to meet you . and catherine will be right in to get your photos . julia jones is a 25 year old female with symptomatic macromastia , presenting for evaluation of breast reduction . the patient has attempted nonsurgical treatments , but the minimal relief , and is an ideal candidate for bilateral reduction mammoplasty . her minimum required resection , based on a bsa of 2.65 , with the schnur scale is 1,792 grams , which should be attainable . given her extremely large breasts and the measurements above , there is potential for using a nipple graft . [doctor] physical exam findings of breast , inspection reveals asymmetrical breasts with severe ptosis bilaterally . there is no nipple retraction or discharge bilaterally . no breast tenderness , masses , or axillary lymphadenopathy is palpable .

ASSESSMENT • Macromastia. Julia Jones is a 25-year-old female with symptomatic macromastia presenting for evaluation of breast reduction. The patient has attempted non-surgical treatments with minimal relief and is an ideal candidate for bilateral reduction mammoplasty. Her minimum required resection based on a BSA of 2.65 with the Schnur scale is 1792 g, which should be attainable. Given her extremely large breasts and the measurements above, there is potential for using a free nipple graft. PLAN An extensive discussion of breast reduction surgery was performed with the patient with consideration of the patient's age, co-morbidities, previous surgical history, body habitus, BMI, and smoking history. Surgical time, immediate recovery course, and longer term recovery course were discussed. Relief of the patient's current symptoms related to macromastia was not guaranteed though is expected to improve. Specific breast size was discussed, also not guaranteed. I explained the expected outcomes of using a free nipple graft such as an insensate nipple and an inability to breast feed. The patient understands that the decision for a free nipple graft will be made intraoperatively based on assessment of nipple perfusion. Risks and benefits of were discussed with the patient The patient understands the above risks, benefits and alternatives to surgery and wishes to proceed with bilateral reduction mammaplasty. The patient will be switching to a different insurance policy in 07/2021. Once we get the new insurance information from the patient, we will submit it to her insurance company. If approved, she will return for preoperative counseling and consent. Return to clinic prior to scheduled surgery date for preoperative counseling and consent."

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you [patient] sure i've been having some back pain on my right side it's been lasting for about a week now [doctor] okay [patient] and i also started to see some blood in my urine [doctor] okay so on the right side so does that pain does it move anywhere or is it just kinda stay in that that one area [patient] yeah it's moved down a little bit on to my right lower side a little bit [doctor] side okay so how would you describe the pain is it constant or is does it come and go [patient] it's pretty constant [doctor] okay did you notice any pain when you're urinating i know i know you say you you saw you see blood but any pain with that [patient] no no real pain when i'm when i'm peeing at all [doctor] okay so have you taken anything i know have you tried like azo or any of that to [patient] i took some ibuprofen that helped a little bit [doctor] okay [patient] but it still hurts even with ibuprofen [doctor] alright have you noticed any nausea vomiting fever chills [patient] i have n't thrown up but i felt a little bit nauseated [doctor] little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but [patient] yeah my my dad had kidney stones i think he has passed a couple of them i'm not quite sure [doctor] alright and have you had any in the past or is this your first one [patient] this is my first time i've never had this before [doctor] okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that [patient] yeah yeah i had some pain over the weekend i saw my pediatrician this morning so they sent me over here they were concerned that i might have a kidney stone [doctor] okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain [patient] not so much but i i got to participate a little bit i opened some eggs i just did n't go run around and find them [doctor] okay well i i'm lucky enough my friends had an adult easter hag hunt for me and so i was able to find a couple eggs yesterday myself so i i'm glad you were able to get a few of them alright so let's do that that physical exam on you so your vitals look good you do n't have any fever your blood pressure heart rate is fine so when i press here on your belly does that hurt [patient] a little bit yeah [doctor] a little bit alright so on your exam of your abdomen there is mild pain and tenderness to palpation of the abdomen there's no rebound or guarding there is cva located near your flank tenderness on the right so that means that everything looks good but you do have what seems to be some inflammation of your kidney okay so we we were able to get a ct of your your side and it showed that you do have a stone measuring point five centimeters in size and it's located in the proximal right ureter and so that's that duck that passes from your kidney to your bladder alright i do n't see any evidence of hydronephrosis so that means that there's not obstructing ureter causing swelling in your kidney which is which is pretty good so let's talk a little bit about my assessment and plan so you do have that kidney stone on the right so what i'm recommending is i want you to push fluids just to help facilitate you passing that stone alright have you been taking in have you been drinking enough water do you think so far [patient] probably not enough i drink some but [doctor] okay yeah i i want you to to drink try drink as much as possible just to see if we can get you hydrated and pass the stone what i'm gon na do is i'm gon na prescribe you ibuprofen eight hundred milligrams you can take that as needed for pain i know you said you were in that much pain just in case it does start to move you're in pain i want you to take the ibuprofen i'm also gon na give you a strainer for you to strain your pee so we can see you wan na know when that that stone does pass gon na order a bmp and a urinalysis and a urine culture and based on what the urinalysis shows we can decide if i can decide if i need to put you on antibiotics if you do have an infection of some kind and i wan na see you back in about a week to two weeks and if you're still having symptoms we can discuss further treatment such as a lithotripsy and it's it's a mainly minimally invasive procedure where we use shock waves to try to break up that stone but otherwise do you have any other questions for me [patient] no i do n't think so [doctor] alright so we will see you back in a week or two and i'll have my nurse come in with that prescription and hopefully with all the treatment you'll be able to pass the stone okay alright

ASSESSMENT Kidney stone, right side. PLAN After reviewing the patient's examination and CT results, I discussed the findings with the patient. The CT scan revealed a 0.5 cm kidney stone in the proximal right ureter. I advised her to drink plenty of fluids, as much as possible, to help facilitate passing of the stone. She was provided with a urine strainer so she can see if and when the stone passes. Given that over-the-counter ibuprofen is not providing significant relief, we will send in a prescription for ibuprofen 800 mg to help with her pain. I'm also going to order a BMP, urinalysis, and a urine culture for further evaluation. Depending on the results of the urinalysis, we may need to start her on antibiotics. I want to see her back in 2 weeks. If she is still symptomatic at that time, we may need to consider further treatment such as a lithotripsy. This procedure was explained to the patient.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] so gloria is a 46 -year-old female today with past medical history of diabetes and back pain and today here for shortness of breath with chf and copd also so gloria tell me what's going on [patient] i i i'm having a lot of trouble sleeping [doctor] okay and and how long has this been going on for [patient] really just for about the past two weeks i i just ca n't ca n't get comfortable you know when i when i lay down in bed i just ca n't ca n't fall [doctor] is it because you're having you ca n't sleep or you're having shortness of breath or difficulty breathing or what's going on with that [patient] yeah i i feel like i'm just i'm just choking a few minutes after i i lay down to sleep i just ca n't catch my breath [doctor] okay and are you and how has your pulse ox been your oxygen level been at home i know you your oxygen level here is like ninety two right now in the office which is a little bit on the low side how is how has that been at home [patient] i can breathe fine [doctor] just when you lay down you get short of breath okay and is it worse when you have you noticed any shortness of breath during the day when you exert yourself when you climb stairs or do other stuff [patient] i do n't i do n't do any of that usually i just i i sit on the couch and watch my shows [doctor] okay fair enough and how about have you noticed any weight gain or swelling in your legs or calves or anything like that [patient] yeah i i ca n't see my ankles anymore and and yeah i i do n't know what's going on with the scale i think the numbers are off because you know suddenly i gained about ten pounds [doctor] wow okay alright and are you taking i know you were supposed to be taking lasix and we had you on you know diet control to to prevent to limit your salt intake how is that going [patient] i i i do n't know how much salt is in freedoes but you know i i i'm really enjoying those in last weekend we got this really big party and yeah which color is that lasix pill [doctor] yeah it's it's the white one the round one so it sounds like you're not maybe not taking it as regularly as you should [patient] no sir i i do n't think i am [doctor] okay alright and are you having any chest pain or tightness in your chest or anything like that or not really [patient] no not really [doctor] okay [patient] just just when i ca n't breathe good at night you know [doctor] okay got it [patient] yeah [doctor] so i'll examine you in a second so it's been a couple of weeks are you coughing up anything any fevers with this at all [patient] no no fever kinda feel like i'm just bringing a whole bunch of yuck up once in a while though especially first thing in the morning [doctor] okay alright and how have your blood sugars been doing this time i know you're taking the metformin are you checking your accu-cheks how has that been going [patient] i i'm sorry what's an accu-chek [doctor] for your blood sugar check are you checking that or not really [patient] i i i did it a couple of weeks ago [doctor] okay [patient] and it was about it i i think about two thirty it was okay [doctor] okay so your hemoglobin a1c last time was seven . five and we had talked about you know trying to improve your diet we had talked about you know we wan na avoid going to insulin but it sounds like it's been a challenge to kinda control the diet and also your blood sugars have been running a little bit high [patient] yeah [doctor] okay alright [patient] yeah it's it's been a challenge [doctor] alright and any nausea vomiting or diarrhea or anything like that are you peeing a whole lot or anything like that no [patient] yeah i'm feeling like crazy [doctor] okay alright [patient] ca n't figure out why because i'm not drinking very much [doctor] alright and how is your back then has that been okay i know you're sitting you said you're sitting on the couch a lot watching tv but [patient] yeah [doctor] besides that anything else [patient] yeah you know it it just it just really hurts so you know and so that's why i sit on the couch so much [doctor] okay alright no weakness or numbness in your legs right now [patient] no [doctor] okay [patient] no [doctor] so let me examine you now gloria i'm gon na go ahead and do an exam and let's pretend i did my exam i'm just gon na verbalize some of my findings just so i can record this and put it into my my into my chart so neck exam you do have a little bit of swelling in your neck little bit of jvd no bruits your lung exam you have some crackles in both bases and some rales that i can hear and there are a little bit of intermittent wheezing as well on your heart exam you have a two over six systolic ejection murmur you've had that in the past otherwise regular rate and rhythm it does n't feel a regular your belly exam your belly's slightly distended there's no tenderness or guarding or anything like that so that does n't that looks pretty good on your leg exam you do have some one plus pitting edema or actually almost one and a half plus pitting edema in your both of your ankles no calf tenderness negative homans sign that means no blood clots otherwise neurologic exam is normal the rest of your exam is normal so what does this all mean so let me explain that so for the first problem the shortness of breath you know i think you have an exacerbation of your congestive heart failure what i'd like to do is increase your dose of lasix from twenty milligrams to sixty milligrams for the next four days i'm gon na have you check your weights everyday and also i'm gon na go ahead and have you use your albuterol and atrovent we had given you some inhalers in the past i can give you another refill if you need to help with that some of the breathing that you're having the shortness of breath so i'd like to get some of this fluid off you have you check your weights daily we'll have you increase your dose of lasix we'll have you use a breathing treatments and see if that helps your shortness of breath i'd like to have you come back in about couple days actually i wan na see how you're doing and if it does n't get better we may have to increase the dose or send you to the hospital okay [patient] i do n't want to go to the hospital doctor [doctor] yeah so let's try to let's try to use the lasix and let's try to let's try to you know use the breathing treatments and and do that for the second problem the diabetes that we just talked about i like to go ahead and order another blood test another hemoglobin a1c i think we need to your blood sugars have been running a little bit high in the past and we've had a hard time but it's been a while since we checked your last one so i wan na check another one today to see where we are and when we have you come back in a couple days we should have the results back we can then adjust your metformin or we may have to adjust some of the you know add a different medication at that point but but right now i'm gon na order some blood tests we'll have you come back in a couple of days and then we can reassess at that point okay [patient] so i had a piece of cake before i came in here is that gon na affect the the lab work [doctor] yeah we'll probably do a fasting blood sugar we'll we'll order the hemoglobin a1c that should n't be actually matter because that checks long term but if we need your blood sugar may be elevated today i i would n't be surprised alright and i forgot to examine your back by the way so on your back exam you do have some tenderness in the paraspinal areas of your back in the in the lower back mostly no midline tenderness you have good reflexes so i think this is all muscular pain right now for your back pain i'm gon na go ahead and put you on some naprosyn and some flexeril which is a muscle relaxer i'm gon na give you some exercises you can do to help you get off the couch it'll also help your blood sugar and why do n't we have you if that does n't work the the pain medicine and the physical we can start physical therapy and see if that helps okay [patient] okay [doctor] any questions about that [patient] i do n't think so which color pills [doctor] i think it's a white pill and it's round [patient] okay [doctor] about this big [patient] alright sounds good [doctor] anything else gloria [patient] no that's it [doctor] alright thanks for coming in today

ASSESSMENT AND PLAN 1. Shortness of breath. - Medical Reasoning: I believe this is an exacerbation of her congestive heart failure. - Patient Education and Counseling: I advised the patient to monitor her weight daily. - Medical Treatment: She will increase her dose of Lasix from 20 mg to 60 mg for the next 4 days. She should also use her albuterol and Atrovent inhalers as needed. If her symptoms don't improve in the next couple of days, we will either increase her doses or have her go to the hospital. 2. Diabetes type 2. - Medical Reasoning: Her recent blood glucose levels have been elevated. - Patient Education and Counseling: We discussed the possibility of needing to add another medication to her regimen. - Medical Treatment: We are going to order a repeat hemoglobin A1c and adjust her dose of metformin accordingly. 3. Back pain. - Medical Reasoning: This appears to be all muscular pain. - Patient Education and Counseling: We discussed exercises she can do to help her pain and that ff this doesn't help we can consider physical therapy. - Medical Treatment: Prescriptions provided for Naprosyn and Flexeril.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hey gabriel i'm doctor scott good to see you today i know you've heard about dax is it okay if i tell dax a little bit about you [patient] sure [doctor] okay so gabriel is a 43 -year-old male today here for back pain evaluation and also has a past medical history of diabetes high blood pressure and high cholesterol so gabriel tell me what's going on with your back [patient] well i was working in the yard and you know bent over to pick something up and i got this pain and you know across the lower part of my back and then it went down my left leg and you know it's been going on for about four days and just does n't seem to be getting any better [doctor] okay are you a big gardener or this is something that you just started working in the yard [patient] yeah i know my wife held a gun to my head make me go out there work in the yard and carry some stuff around it's not my not my first choice but [doctor] sure sure [patient] but that day i i lost the i lost the argument [doctor] yeah yeah that happens to all of this so when this back pain happened so it was basically you were lifting you were bending down to lift something up and you had the sharp pain going down your right leg you said [patient] left leg [doctor] left leg okay got it sorry and any weakness or numbness in your legs or just the pain mostly [patient] in in certain positions i get some tingling but no mostly just pain [doctor] okay and any loss of bowel or bladder function at all or anything like that [patient] no [doctor] okay and have you had any back surgeries or back problems in the past or this is kind of the first time [patient] no surgeries you know i've i've had back pain occasionally over the years [doctor] okay have you had any any have you tried anything for pain for this have you tried any any medications at all [patient] i've had ibuprofen it it helped some [doctor] okay got it alright well i'll i'll examine you in a second but before we do that let's talk about some of the other conditions that we're kinda following you for i'm looking at your problem list now and you've got a history of diabetes and you're on metformin five hundred milligram twice a day and your how are you doing with your blood sugars and your and your diet and exercise [patient] yeah i i check my sugar two or three times a week most of the time it's in that one twenty to one forty range [doctor] okay [patient] yeah i take my medicine okay my diet is alright you know i could be fifteen pounds lighter that would be alright but [doctor] sure [patient] i i i think the sugar has been okay [doctor] okay we checked your hemoglobin a1c last time i'm looking at your records in epic and it showed that it was you know seven . one so it's it's it's good but it could be better any you know we talked about it controlling your diet or improving your diet and trying to have a balanced meal and not eating some of these sweets and high sugar items how is that going i know you had talked about your wife being a great cook and making cookies and that's hard to stay away from obviously how are things going with that [patient] yeah she still makes cookies and i still eat them but you know we are trying to trying to do better trying to stay away from more of those carbs and focus on you know less carby less sweet stuff [doctor] okay alright yeah that's always a struggle i certainly understand but you know really important with your diabetes just to prevent some of the complications like kidney failure and eye problems and just keep your sugar under balance so i'll order another hemoglobin a1c today we'll check that again today and and you know just reemphasizing the controlling your diet and exercise is super important and then we'll have those results back we'll we'll see if we need to make any modifications okay [patient] okay [doctor] for your high blood pressure your blood pressure in the clinic looks pretty good it's about one twenty over seventy right now we have you on norvasc five milligrams once a day how are things going with that are you are you checking that periodically or any issues with that at all [patient] yeah i guess i check it maybe once a week or two or three times a month and it it the vast majority of the time when i check it it's good usually either that one twenty to one thirty over seventy to eighty range i i think the blood pressure's okay [doctor] okay [patient] i have n't had any real problems there i i have had some some swelling in my ankles though [doctor] okay is that new or is that been going on for a while [patient] well it it started maybe i do n't know a month or two after i started the norvasc [doctor] okay [patient] and i was just wondering if the two might be related [doctor] yeah i mean certainly it could be it is you know sometimes that medication can cause that so i'll i'll examine you in a second and see if we need to make any modifications okay [patient] okay [doctor] alright so and your anything else bothering you today [patient] no i'm we're doing okay i think [doctor] so let me examine you for a second i'm gon na go ahead and gabriel i'm gon na do my magic exam now let's pretend i i'm just gon na verbalize some of my findings as i do my exam and so [patient] these are like my video visit exams [doctor] exactly so your neck exam has no jvd there is no bruits that i can hear your lung exam no rales no wheezing on your heart exam you do have a two over six systolic ejection murmur you had that in the past so i'm not too worried about that otherwise regular rate and rhythm on your heart exam on your on your on your belly exam is nice and soft on your back exam you do have some tenderness on the left paraspinal area right where i'm pressing right there your straight leg raise test is negative your reflexes are normal you have some just some tenderness in the lower back in the paraspinal area of your back when i palpate there otherwise your neurological exam is normal on your extremity exam you do have this one plus nonpitting edema of your lower extremities which is a little bit of swelling in your ankles no calf tenderness negative homans sign no signs of blood clot that's what that means so let me just review what you know explain what all this means so the back pain the first problem that you're here today for i think this is more of a muscular sprain i'm gon na recommend we start you on some anti-inflammatory naprosyn five hundred five hundred milligrams twice a day and flexeril ten milligrams twice a day as well i'm gon na refer you to for for physical therapy to help strengthen some of the muscles in your lower back i do n't think you need an x-ray at this stage why do n't we start with physical therapy and the muscle relaxers and the pain medicines if it does n't get better then we can get an x-ray but right now i would start with that if that's okay with you any questions about that [patient] no [doctor] okay for the diabetes the the second problem that we talked about today i'm gon na order another hemoglobin a1c continue the metformin five hundred milligrams twice a day why do n't we have you come back in about two weeks and we should have some of the results back and we can discuss if we need to make any modifications for that but right now we will continue the course and we will go from there okay for the high blood pressure you do have this one plus edema in your legs i'm gon na go ahead and order some blood work today i'm gon na go ahead and stop the norvasc and we'll put you on some hydrochlorothiazide ten milligrams once a day and if that does n't get if the swelling does n't go away i'm gon na do some more testing for right now let's get some sort off with some cbc and a bmp i'm gon na check your kidney function i'm gon na get another ekg and also i'm gon na get a chest x-ray and we'll go from there but hopefully this will go away once we stop this medication since it started around that time okay okay and i think that's it anything else we forgot about do you need refills for anything [patient] no i i think i'm okay you gave me a year's worth of refills last time we were together [doctor] okay sounds great alright thanks gabriel good seeing you again [patient] good to see you thanks

ASSESSMENT AND PLAN 1. Lower back pain. - Medical Reasoning: I believe this is more of a muscular sprain. - Patient Education and Counseling: We discussed treatment options today. - Medical Treatment: I am going to start him on Naprosyn 500 mg twice a day and Flexeril 10 mg twice a day. I will refer him for physical therapy to help strengthen some of the muscles in his lower back. - Additional Testing: I do not think he needs an x-ray at this stage, however if he does not improve, we will order one for further evaluation. 2. Diabetes. - Medical Reasoning: His most recent A1c was 7.1 and his blood sugar levels are typically between 120-140. - Patient Education and Counseling: We discussed treatment options today. - Medical Treatment: He will continue the metformin 500 mg twice a day. - Additional Testing: I am going to order another hemoglobin A1c. 3. Hypertension. - Medical Reasoning: He does have 1+ edema in his legs. - Patient Education and Counseling: We discussed treatment options today. I explained that his edema is likely caused by the Norvasc. - Medical Treatment: The patient will discontinue the use of Norvasc and we will start him on hydrochlorothiazide 10 mg once a day. - Additional Testing: I will order a CBC and BMP. Additionally, I will order a repeat EKG, as well as a chest x-ray.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] alright you can go ahead [patient] hey alan i good to see you today so i looked here my appointment notes and i see that you're coming in you had some shoulder pain left shoulder pain for the last three weeks so [doctor] how you doing is it is it gotten any better [patient] yeah yeah i've been having a lot of pain of my shoulder for the last three weeks now and it's not getting better okay do you remember what you were doing when the pain first started [doctor] so i i was thinking that i i ca n't recall like falling on it injuring it getting hit [patient] hmmm [doctor] i have been doing a lot of work in my basement and i even i put in a new ceiling so i do n't know if it's from all that activity doing that but otherwise that's that's all i can think of [patient] okay so do you remember hitting it or anything like that [doctor] no nothing at all [patient] okay alright did you fall do you remember doing that [doctor] no [patient] okay hmmm so like a little mystery so have you had pain in that shoulder before [doctor] i mean i'm very active so i can get pains in my shoulders but it's nothing that sometime some tylenol can help [patient] okay and are you able to move the arm or is it kinda just stuck [doctor] i'm having a lot of pain like i can move it but you know when i try to reach for something lifting anything and even like i do n't even try to put my hands over my head because it causes so much pain [patient] alright so does that pain radiate anywhere or like where would you say it is in your shoulder [doctor] it actually it stays pretty much just right at the shoulder it does n't go down anywhere [patient] okay and the pain is it is it all the time or does it come and go [doctor] it's pretty much all the time anytime i put any pressure on it like when i'm trying to sleep it hurts even more so it's been affecting my sleep as well [patient] okay so i know you mentioned tylenol so this time i have n't taken anything for it [doctor] yeah i i do the tylenol which usually works for me and it does take the edge off but i still have pain okay did you try icing it at all [patient] i iced it initially but i have n't iced it at all recently [doctor] alright [patient] and so with your shoulder have you experienced any numbness in your arm or in your fingers [doctor] no numbness or tingling [patient] okay good so i'm gon na go ahead and do a quick physical exam and take a look at your your shoulder so i reviewed your your vitals everything looks good with that so touch here in your shoulder so your left shoulder exam you have limited active and passive range of motion so pressure here so that there is tenderness of the greater [doctor] okay [patient] tuberosity of the humerus let's see there is no tenderness at the sternoclavicular or acro [doctor] yeah [patient] acromioclavicular joints [doctor] yeah yeah [patient] and looks like you have good hand grip let me see so on the neurovascular exam of your left arm your capillary refill is less than three seconds and your sensation is is intact to light touch [doctor] yes thank you yep [patient] so you did get a we get we had to get a x-ray of your shoulder before you came in and so it's normal so that's really good so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you you do have that left shoulder pain so your symptoms are [doctor] most likely due to a rotator cuff tendinopathy so this means that you injured tendon you have injured tendons and muscles that make up your shoulder and make up your shoulder muscles so what i'm gon na do is i'm gon na order an mri of your left shoulder [patient] and so we're gon na begin with that just to make sure nothing else is going on have you done physical therapy before [doctor] i have n't [patient] okay so what i'm gon na do i'm going to refer you to physical therapy for approximately six to eight weeks and so they can help you strengthen those muscles around your shoulder and that should definitely help with the pain during that time you can also continue to take tylenol i do n't think i need to prescribe anything else for the pain you said as it's working pretty good for you so if your symptoms do n't improve we can consider a steroid injection of your shoulder which should provide some relief but i think right now we can just go with the the pt and hopefully that works to alleviate your injury so do you have any questions about the plan [doctor] so like i said i'm really active do you think that this pain will ever go away [patient] yeah so many patients are very successful with rehab and so we'll start with that and see how you do most most of the time once we build up those muscles around that shoulder you know things things the pain alleviates itself and and and you will be good to go back to working on your basement and running and jogging and lifting weights all all the active things people do these days [doctor] okay alright thank you [patient] bye [doctor] okay bye

ASSESSMENT Left shoulder pain, likely rotator cuff tendinopathy. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding his current symptoms. I have explained that his x-rays did not reveal any signs of a fracture. I have recommended that we obtain an MRI of the left shoulder to evaluate for possible rotator cuff tendinopathy. The patient was provided with a referral to formal physical therapy. He will engage in a 6-to-8-week course in order to strengthen his left shoulder. I have also advised him to take Tylenol as needed for pain. If his symptoms do not improve, we may consider a steroid injection to the left shoulder.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

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

ASSESSMENT AND PLAN Anna Mitchell is a 44-year-old female with a past medical history significant for arthritis, gout, and reflux, who presents today for follow-up of her chronic problems. Acid reflux with nausea and vomiting. • Medical Reasoning: She reports episodes of vomiting in the morning, as well as abdominal pain and bloating. She has been compliant with omeprazole and has made a few dietary modifications. • Additional Testing: We will order an ultrasound of her right upper quadrant, as well as additional labs, to rule out biliary etiology. • Medical Treatment: Continue omeprazole 40 mg once daily. • Patient Education and Counseling: I encouraged her to continue with dietary modifications. Gout. • Medical Reasoning: Her flares are well controlled on allopurinol. • Medical Treatment: Continue allopurinol 100 mg once daily. This was refilled today. Arthritis. • Medical Reasoning: She is doing well and has remained active since her last visit. Physical therapy has also been beneficial for her. Her right knee x-ray demonstrated residual arthritis but was otherwise normal. • Patient Education and Counseling: I advised her to continue pilates and using the knee. She will contact me if she has any issues and we can consider further imaging or intervention at that time.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hey elijah how are you [patient] i'm doing okay [doctor] so i see here that your primary care provider sent you over it looks like you were doing some yard work yesterday and dropped a landscape brick on your foot can what so what's going on with your right foot today [patient] it's a little sore today but you know i hurt my foot before but this is the first time where i'm actually being seen for it [doctor] okay so you say you've injured your right foot before tell me a little bit about that injury [patient] twenty years ago i broke my ankle i had to put in a cast but that seems to be okay but you know sometimes it'll give me trouble once in a while it feels a little sore it swells up at times [doctor] okay [patient] and my other ankle too is sore sometimes and i've had surgery for that too and you know one of those things where you know it might give out once in a while but i'm not sure that's related to what the you know break dropping on my foot but you know either way my foot's a little sore [doctor] okay alright so when you dropped that brick on your foot were you able to get up and keep working or did you have to get off your you know not stop weightbearing and and get off that foot can you tell me a little bit about after the traumatic incident [patient] i you know it was a little sore i called a few names you know god damn why is this in my foot but you know i kept working putting it around a little bit but now it's got swollen so i got to see my doctor he told me i had to go see you here i am so tell me what's going on with it [doctor] so what have you been doing for the pain since the initial insult [patient] lucken it up [doctor] okay have you taken any medications safe for example tylenol or ibuprofen for the pain [patient] no i feel like taking the medicine [doctor] okay and then just out of curiosity you said you were doing some landscaping have you been over to landscapes warehouse new here in town my wife and i were just over there this last weekend and picked up a whole bunch of stuff you had a chance to make it over there yet [patient] no not yet i heard about it though i might have to make a trip once my foot heals [doctor] alright that sounds good now just out of curiosity can you rate your pain for me right now zero being none ten being the worst pain you've ever been in your life [patient] eleven out of ten [doctor] okay and then have you experienced any numbness or tingling of that foot since the incident [patient] yeah the whole foot is numb [doctor] okay [patient] but been now for a long time [doctor] okay i'm gon na do a quick physical exam now your vitals look good and i would like to do a focused exam of your right foot the there is some bruising on the bottom part of your foot and on the top part as well and i do appreciate the associated swelling and i also recognize that you do have tenderness to palpation for midfoot now for your neurovascular exam of your right foot your capillary refill is brisk in less than three seconds i do note a strong bounding dorsalis pedis pulse with motor and sensation is intact for that foot i also like to call out the fact that it matches bilaterally which is important i'm gon na go ahead and review the diagnostic imaging results so we did a x-ray of that right foot and i do notice dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and presence of bony fragments so let me tell you a little bit about my assessment and plan now your right foot pain is due to a lisfranc fracture which is a fracture to your second metatarsal bone and the top of your foot this is where the metatarsals meet those cuboids okay so it where the bones come together in your foot now there are a lot of ligaments in your foot so i do want to order an mri just to assess if there is any injuries to those ligaments now based on your exam and looking at the x-ray you're most likely going to need surgery now the reason why this is important is if we have poor bone alignment or ligament healing you can this can lead to losing the arch in your foot you could becoming flat-footed and also developing arthritis now what's gon na be key here is the surgery is going to allow those bones and ligaments to heal properly we are going to put them back into place using plates and screws now the key thing is going to be it's going to be outpatient surgery so it's going to be same day i'll see you in the morning and then you'll be discharged home that evening and we will do a follow-up i wan na see you in twenty four hours post procedure but then i'll see you again in two weeks you're gon na be in a cast and i'm gon na have you use crutches you're not gon na be able to weight-bear on that foot for six to eight weeks what we'll do is we'll advance your ambulating gradually based on how you heal and based on how you tolerate the procedure i know i have covered a lot of material quickly but this is really gon na be the best course of action for you to have a good outcome now do you have any questions come answers concerns before i have the nurse come in finish the paperwork and get you set up for your procedure which we are going to do tomorrow if you're agreeable to that [patient] what about putting in a cast can i just stay in the cast [doctor] you could but what we found is the best outcome is aligning those bones with plates and screws to make sure that they heal properly so you have the best outcome possible [patient] so if the surgery is going to be tomorrow when am i going to get my mri [doctor] so what what we will do is the good news is we have an outpatient mri facility downstairs and i'm going to send the order down and we'll get you your mri this afternoon [patient] can i think about it and we have some time [doctor] sure [patient] okay [doctor] alright thanks elijah

ASSESSMENT Right foot pain, due to a Lisfranc fracture. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with him regarding his current symptoms. We discussed treatment options and I have recommended that we proceed with a right foot ORIF and all indicated procedures. We reviewed the risks, benefits, and alternatives of the surgery. I advised him that this procedure will be performed in an outpatient setting and he will be discharged home that same evening. He will then follow up with me 24 hours post procedure, and again 2 weeks later. I explained that he will be placed in a cast and will remain non-weight-bearing for 6 to 8 weeks. He will use crutches while ambulating and we will advance his weight-bearing gradually based on how he tolerates the procedure. I have also recommended that we obtain an MRI of the right foot to further assess the ligaments. I explained to him that if he has poor bone alignment or ligament healing, this can lead to losing the arch in his foot causing pes planus and developing arthritis. I will send an order to the outpatient MRI facility downstairs for him to obtain the MRI this afternoon. The patient wishes to think over his options before proceeding with the operation."

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] alright [patient] good morning Julie how are you doing today [doctor] i'm doing okay i'm just a little nervous about what's been going on with my headaches [patient] okay so i know you were sent here by your your pcp what was your understanding of why you were sent here [doctor] yeah so i actually have been someone who been struggling with headaches for years now ever since i was a teenager and they used to be around my when i would have my menstrual my menses but as i got older i noticed that it has been with that and also i can get it when i'm really stressed but recently and why i went to her is because my headaches have been getting a lot more they've just been happening a lot more frequently and a lot more severe [patient] okay can you tell me a little bit about them what how do they how do they feel when they come on [doctor] so they say mostly on my right side and it even seems like it's like behind my eye and it just like this pulsing like this really bad pulsing sensation [patient] okay do you notice these any activities or time of the day that makes them worse i know you said they they seem to get worse around your menstrual periods but is there any time of the day or that makes them worse [doctor] i i have noticed that you know i've been trying to exercise more in order to lose weight but i ca n't even really exercise for very long because i start of as soon as i start to jog i my headaches the headaches come back on a lot worse so i notice it when i'm exercising [patient] okay and do you seem to have any other symptoms when you get these headaches i've been having a ringing in my ears for a few months now and then what really scared me is that now i'm starting to get some blurred vision it's not all the time but it it will come and go but some blurred like on the [doctor] in my on the side of my vision [patient] okay okay and have you experienced any numbness or tingling to your hands or feet or your face [doctor] no i have n't [patient] okay so you you like to run a lot what kind of do you do you use a a good shoe you know what kind of shoes do you use for your running [doctor] yeah i yeah i i'm starting to get back into it i'm a big new balance person in asics so yeah those are the two brands i like to wear yeah so right now i'm using asics [patient] okay yeah i like to run too and i use nike [doctor] okay [patient] i used to get tumor guy but i i really kinda moved over to nike [doctor] hmmm [patient] that's good you know it is running is a great exercise [doctor] it is [patient] so have you had any let's get back to the exam here have you had a recent mri of your brain i saw one from a few years ago but as doctor white said anything about getting a more a recent mri [doctor] yeah she was gon na put one in but she wanted me to see you first and urgently so they have n't called me yet for the mri [patient] okay so that's good we i think we'll we will follow up with that mri but let's go ahead and take a do a quick physical exam here i reviewed your vitals that the the assistant collected when you came in and everything there looks good including your blood pressure you know with symptoms like that that's one of those things that i'd be concerned about [doctor] okay [patient] now on your heart exam it sounds like it's normal sinus rhythm with no murmurs rubs or gallops so that's good as i listen i'm gon na go ahead and look here in your eyes the funduscopic exam shows papilledema and that's just some of swelling behind there in the eye and this let me do a a neurological exam this will take a few minutes you get up to follow my instructions as we go through that okay on neurological exam your cranial nerves one through twelve are intact including a normal cranial reflex and just went to watch you walk across the room here [doctor] okay turn around come back and okay so on musculoskeletal exam your gait is normal [doctor] okay go ahead sorry [patient] that's okay for your first problem your headaches your symptoms are concerning for what we call idiopathic intracranial hypertension and this is a condition that that you have increased pressure in the in your head in your brain without any known cause for it now patient also presents with often present with symptoms such as yours you know headaches worsening with activity ringing in the ears changes in your vision so i'm i'm pretty confident that that's what we're having here now why we get concerned is if the pressure continues to increase this can lead to some permanent changes in your vision so i i do wan na get a a few more tests just so we can confirm that diagnosis and the first one that we just talked about is an mri i think it's really important to get that to check for any other condition that could be contributing to your symptoms now once i have that result i'm gon na be doing also doing a spinal tap which will help me evaluate the pressure in the brain and it can also help you feel better if you do have an increased pressure by taking the decreasing the amount of that pressure just by taking a a a little bit of fluid off of that and lastly i want you to be seen by a neuro-ophthalmologist for a complete eye exam now i i know that sounds like a lot of information but i think it's really important we get that accomplished do you have any questions for me [doctor] yeah that is a lot and so i i'm sure i'll have more that comes up but so let's say we do all this test and it confirms what you're saying does that mean was i referred to you because that means i will need surgery [patient] not necessarily if you have idiopathic intracranial hypertension there are number of medications that we can try to help decrease that pressure in your brain and this will also help you have less headaches when you exercise as exercise and weight loss are also an important part of the treatment [doctor] okay alright alright and i'll probably add something about so is this something i'll be doing soon is this all things i'll be doing this week [patient] yeah that's a great question here i i'm gon na go ahead and we're gon na for the mri i'll have to get a preapproval from your insurance company i will work on that my my my team in the front office will get that preapproved and then once that's done we'll call you to help schedule that mri [doctor] okay alright thank you bye [patient] bye sorry

ASSESSMENT Headaches, concern for idiopathic intracranial hypertension. PLAN After reviewing the patient's examination today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have recommended that we obtain an urgent MRI of the brain to evaluate for any other condition that could be contributing to her symptoms. We will contact her to schedule this after approved by insurance. Once the MRI results are available for review and further discussion, I will also perform a spinal tap to evaluate the pressure in the brain. I have also advised her to be seen by a neuro ophthalmologist for a complete eye exam. Questions were invited and answered today. The patient agrees to the treatment plan.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] all right . today i am seeing jose james . uh , date of birth 9/29/1957 . mr . james is a new patient who's having pain in his left shoulder and elbow . he fell five months ago going up a stairs , and the pain has been present since . [doctor] hi mr . james , i'm doctor isabella . how are you doing ? [patient] i'm okay . thank you . [doctor] that's good . that's good . tell me what's brings you in today . [patient] sure . so i've been having constant pain in my left shoulder and left elbow for a while , about five months or so . hurts all the time . pretty bad at times . [doctor] mm . that does not sound like fun . it sounds like you injured it going up the stairs ? [patient] yes , that's correct . it was icy , and i have to walk up a flight of stairs to my house . i stepped and my feet just went out . fell on my left side . seems like my shoulder and wrist took the brunt . it's been hurting since . [doctor] yeah , that does seem like a likely cause of your symptoms . anything seem to make the pain worse ? [patient] well , i've always hit the gym and lifted weights . i've been trying to keep with my routine of two days a week , but it's been hard . the pain is worse when i lift , and i have n't been able to lift more than 15 or 20 pounds which is very frustrating . [doctor] mm-hmm . i can imagine it is when you're so accustomed to your routine . [patient] exactly . i really enjoy my exercise , but over the past one to two weeks , i've stopped hitting the gym because the pain just was n't worth it honestly . i do keep up with my walking , though . my wife and i walk about 30 minutes almost every day . we have done this since i retired from my office job last year . [doctor] i do not blame you , mr . james . does anything seem to help the pain that you've tried ? [patient] not too much . i have iced a bit , but i have not taken anything for the pain . stopping exercise and some ice has helped a bit , but it still hurts enough for me to come to see you . [doctor] yeah , okay . how about any numbness or tingling ? have you felt that at any point ? [patient] no , doc . just pain . no tingling or numbless , numbness , thankfully . [doctor] understood . understood . all right . well , let's go ahead and take a look and see what's going on . [patient] sounds good . thank you . [doctor] okay . use my general physical exam template . mr . james , i'm going to gently press around your shoulder and elbow here to see where your pain might be stemming from . just let me know when it hurts . [patient] okay . it hurts when you press there on my elbow and here on my shoulder . [doctor] okay . left shoulder and elbow , tender sa space , no warmth , erythema or deformity . positive hawkins-kennedy and neer's test . normal proximal and distar , distal upper extremity strength . intact median radial ulnar sensation and abduction to 90 degrees . normal empty tan , can test . okay , mr . james , w-what i think you are dealing with is impingement syndrome of your left shoulder . i do n't think there's an additional injury or issue with your wrist , but because everything is connected , you're experiencing pain in your wrist because of your shoulder . we do see this type of issue when someone has a fall , so it's good you came to see us , you came in to see us so we could help . [patient] so what are the possible treatments ? [doctor] well , we have a few options you can try . first option would be to start with physical therapy . i would recommend two sessions per week as well as any other exercises they give you to do at home . we can start there and if that does n't improve your pain , then we could try a cortisone injection . [patient] i like the idea of starting with the physical therapy and have a next step if it does n't help . i am not opposed to a shot but would like to try the therapy first . [doctor] all right . great . i'll get a referral order , and they will call you within the next day or two to get you scheduled . [patient] okay . [doctor] mm-hmm . also , please continue to ice , especially your shoulder , and rest as much as you can . [patient] okay . i will . [doctor] give us a call or email us if you have symptoms worsen , if your symptoms worsen or do not improve with the therapy . [patient] will do . thank you . i appreciate your help . [doctor] you're welcome . have a great day . [patient] you too . [doctor] all right . assessment is impingement syndrome of left shoulder . plan discussed with patient . referral is requested for dr. martha rivera to be in physical therapy two days per week .

ASSESSMENT • Impingement syndrome of left shoulder Jose is a 64-year-old male who was seen today for impingement syndrome of his left shoulder, likely related to a fall he incurred 5 months ago. PLAN Today I discussed conservative options for left shoulder impingement with the patient, who opted to try physical therapy 2 session per week. Cortisone injection was discussed as an option if the physical therapy does not successfully reduce his pain. Additionally, I recommended continued ice and rest.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] hey mason good to see you today so let's see you here in my notes for evaluation of kidney stones your your pcp said you had some kidney stones so you got a referral over so can you tell me a little bit about that you know what happened when did you first notice them [patient] yeah it was about you know about a week ago and i was working down in the the barn with the horses and you know i was moving some hay but i developed this real sudden onset of pain in my right back and i thought it initially it was from throwing hay but it i broke out into a sweat i got real nauseated and that's when i went and saw my doctor and he ordered a cat scan and said that i had a kidney stone but you know that's i i've never had that before my father's had them in the past but yeah so that's that's how that all happened [doctor] okay so you said you had the pain on the right hand side does it move anywhere or radiate [patient] well when i had it it would it radiated almost down to my groin [doctor] okay [patient] not the whole way down but almost to the groin and since then i have n't had any more pain and it's just been right about there [doctor] okay and is the pain constant or does it come and go [patient] well when i you know after i found out i had a disk a kidney stone it came a couple times but it did n't last as long no i've been i've been straining my urine they told me to pee in this little cup [doctor] mm-hmm [patient] and i've been straining my urine and you know i do n't see anything in there [doctor] okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual [patient] no not really not really darker [doctor] okay so have you had kidney stones before and then you said your father had them but [patient] i've never had a kidney stone my dad had them a lot but i've never had one [doctor] okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means [patient] i have a stroke [doctor] can you repeat that [patient] i did i have a stroke [doctor] no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in the proximal right ureter and that's that duct that classes from your your kidney to down to your bladder there is no evidence of hydronephrosis that would mean that the stone is obstruct obstructing the ureter causing swelling in the kidney so there is there is no evidence of that so let's talk a little bit about my assessment and plan so you do have that kidney stone so right now i'm gon na recommend that we we have you push fluids just to help facilitate you urinating and passing the stone i'm gon na prescribe you some oxycodone five milligrams every six to eight hours for pain and you can continue to take tylenol between that for any breakthrough pain and you already have a strainer so that's good continue to use that and we can see continue that until the stone hasses and i'm also gon na order a bmp and your urinalysis and urine culture just to make sure that everything else is okay with you and based on urinalysis we can see if we need to prescribe you antibiotics see if you have any type of infection i do want to see you back in about one to two weeks and hopefully by that time you you passed the stone but if not we can discuss further treatment lithotripsy it's like a shock wave kinda breaks up that stone it's not it's not that invasive procedure but we can just we can discuss that if it has n't passed in that one to two weeks that sound good [patient] that sounds perfect dear too [doctor] alright [patient] thank you document [doctor] so i will see you in a week or so and hopefully you've passed that stone and i'll send my nurse in with that prescription [patient] okay thank you [doctor] thanks

ASSESSMENT Right kidney stone. PLAN We reviewed the patient's CT results in detail today. I have recommended that we treat the patient conservatively. I have prescribed the patient oxycodone 5 mg every 6 to 8 hours for pain. He may continue to take Tylenol between the oxycodone doses for any breakthrough pain. The patient should continue to use the strainer when he urinates until the stone passes. I have also recommended that we obtain a BMP, urinalysis, and urine culture to evaluate for any signs of infection.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.

[doctor] so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle [patient] well we had a long spring and the other day we got some snow and ice i was walking to my car and i slipped and my left ankle kinda turned underneath me [doctor] okay and so this happened couple days ago or how many days ago [patient] two days ago [doctor] two days ago okay and so it's your left ankle and it kinda just twisted underneath you on the kind of on the inside [patient] yeah more on the it's more on the outside of my hips [doctor] and did you fall down or did you just kind of cut catch yourself [patient] no i fell [doctor] okay and were you able to get up afterwards or somebody helped you up [patient] i was but it was very sore and then started swelling and quite a bit of pain so it's hard to walk [doctor] sure have you tried anything for pain or the swelling or anything like that [patient] ibuprofen some ice and elevation [doctor] okay has that helped much or not really [patient] a little bit [doctor] okay and any pain above your ankle does it hurt on your on your calf or your lower leg at all or knee at all [patient] no it's mostly just the outside of my ankle [doctor] okay got it and no bleeding or i'm sure it's a little swollen probably [patient] yeah it's swollen but no bleeding [doctor] well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood sugars been how how're you managing that any issues with that [patient] no they've been pretty stable [doctor] okay [patient] so with my diet [doctor] good [patient] so [doctor] you're checking your sugars regularly as well [patient] yes [doctor] okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you seen the ophthalmologist recently for your eye exam for your diabetes checkup or no [patient] i am due for one of those in the next couple of weeks [doctor] okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that [patient] i have an appointment [doctor] perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything [patient] i need a refill on that yes [doctor] okay alright well let me examine you here for a second so i'm gon na go ahead and do my match exam and i'm just gon na verbalize some of my findings so i can put that into my record okay so your neck exam is fine there is no bruits your lungs are clear your heart exam is normal you do have a two over six systolic ejection murmur you had that in the past unchanged from before so that's not really worried about that your belly exam is good on your ankle exam on your left ankle you do have some tenderness over the lateral malleolus and you do also have some tenderness over this bone here which is the fifth metatarsal so i do n't see any there is some swelling there some redness but there is some pain with valgus stressing of your ankle as well and let me turn off my phone here and also you do have otherwise normal sensation normal pulses so on your so my diagnosis for your ankle is i think you probably have an ankle sprain but i would like to order an x-ray of your ankle because you do have some tenderness over this bone and i'm sometimes worried about a fracture so i'm gon na go ahead and get an x-ray i'm gon na put you in a splint we're gon na put you in a in an air splint and i'll give you some crutches until i get the x-ray back i want you to do just avoid weightbearing just to make sure there is no fracture there i will give you some naprosyn five hundred milligrams twice a day for pain control keep it elevated put some ice on it i think those are all good things and if the x-ray shows a fracture i'm gon na go ahead and give you a call back and we'll send you to orthopedics but right now let's try this air splint if there is no fracture i will probably have you take off the air splint and do some partial weightbearing and see how it goes does that sound like a reasonable plan for you [patient] that's a great plan i need to get back to exercising so [doctor] okay [patient] thank you [doctor] perfect and for the diabetes keep the eye appointment that you already have you know continue with the metformin i'm gon na order another hemoglobin a1c today we'll check some baseline labs as well since it's been a while since we checked them and then once if you have any issues or you know give me a call we can get you into the office and for the high blood pressure i'll go ahead and refill the norvasc today you're doing a great job with that it sounds like continue to monitor that if something changes certainly call me we can get you in sooner okay [patient] thank you [doctor] sounds good sounds good good great seeing you thanks stephanie [patient] thank you

ASSESSMENT AND PLAN 1. Left ankle pain. - Medical Reasoning: Given the nature of her injury, I believe this is an ankle sprain. - Patient Education and Counseling: I advised the patient that I will contact her with the results of her x-ray, and that if these reveal a fracture, we will put in a referral to orthopedics for further evaluation. - Medical Treatment: X-ray ordered to rule out fracture. We will place her in an air splint and have her ambulate with crutches to avoid weightbearing until we get the x-ray results. She will start Naprosyn 500 mg twice daily for pain control. Continue with ice and elevation. 2. Diabetes type 2. - Medical Reasoning: This appears to be well controlled with her current regimen. - Patient Education and Counseling: I encouraged her to keep her appointment with ophthalmology for her diabetic eye exam. - Medical Treatment: We will keep her on her current dose of metformin and order a repeat hemoglobin A1c. We will also obtain a set of baseline labs. 3. Hypertension. - Medical Reasoning: She is doing well with Norvasc. - Patient Education and Counseling: I encouraged her to continue with home monitoring and knows to contact the office if needed. - Medical Treatment: We will keep her on her current dose of Norvasc. A refill was sent for this today.

Summarize the patient/doctor dialogue into an assessment and plan.

You are a clinical expert and you are summarizing the patient/doctor dialogue into an assessment and plan. Focus on symptoms.