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ACI001
aci
[doctor] hey george how are you today i understand you're here for some numbness and tingling in your fingers and some pain in your wrist [patient] right my left wrist and hand has been bothering me probably for a few months now with pain and numbness [doctor] okay and you said that's been ongoing for several months do you know what caused this type of pain or is it just something that started slowly or [patient] it just kinda started on it's own it i notice it mostly at night [doctor] okay [patient] sometimes it will i'll wake up and my hands asleep and i got ta shake it out [doctor] shake it out and okay [patient] and then some [doctor] what kind of work do you do [patient] i do yard work [doctor] yard work [patient] landscaping landscaping [doctor] landscaping okay so a lot of raking a lot of digging so a lot of repetitive type movements [patient] yeah it's pretty heavy labor but it's yeah the same thing day in and day out [doctor] okay okay just a couple questions for you you did say that you have the pain at night in that and you have to you get that numbness into the hand is it in all the fingers [patient] yeah it seems to happen to all my fingers but i notice it more in my thumb and pointer finger [doctor] okay okay and anything into that little into your fifth finger your little finger any numbness there at times no [patient] sometimes yeah it seems like it's numb too [doctor] okay what about your right hand any problems with that hand [patient] no i do n't seem to have any problems with my right hand so far it's just mostly my left [doctor] okay okay good and just a couple you know do you how do you have many or do you drink often do you have you know many any alcohol consumption [patient] i drink usually a a beer or two on fridays and saturdays on the weekends [doctor] okay and do you have any evidence of any anybody ever said that you had some rheumatoid arthritis in your hand or wrist anything like that [patient] no nobody say anything like that so i mean [doctor] okay okay good so let me go ahead and do a physical exam here real quick and you know i'm gon na quickly just listen to your heart and lungs okay that's good i'd like you to squeeze i'm gon na hold your hands here and i'd like you to squeeze both hands [patient] okay [doctor] you seem a little bit weaker on that left hand is that what you've noticed [patient] yeah i experienced some weakness in my left hand [doctor] okay do you you find that you're dropping things when you're picking it up is it to that level or [patient] yeah i drop things mostly because i have a hard time feeling it [doctor] okay okay good and so you you do have a a grip strength is less on the left and i just wan na touch your fingers here on the on the right side you can feel me touching all the fingers on the right [patient] yeah i can i can say you touch me but it feels a little more weird on the thumb side than my pointer finger side [doctor] okay okay and i wan na turn your wrist over here and turn your hand over and i'm gon na go ahead and tap on the right wrist on the back here does that do anything when i do that [patient] i still i feel a little jolt or a zing in my finger tips [doctor] okay and then when i do that on the left side [patient] yeah same thing [doctor] same thing okay so you do have a bilateral positive tinel's sign so so here's here's where i'm at i think your your diagnosis is beginning to have some bilateral carpal tunnel syndrome usually we see that with repetitive actions such as the landscaping the heavy labor and you you know your your clinical exam and and history sound like it's a carpal tunnel syndrome i do want to order so where are we gon na go from here i would like to order a a study it's called an emg where it it measures some of that electrical impulses down into your fingers we will follow up with that but as far as your treatment so the treatment for carpal tunnel syndrome is really some activity modification now i know you are a landscaper is there any way that you could be work to have some lighter work during the time [patient] i suppose i could try to pass it off to some of my other employes and delegate [doctor] okay that would be good so that's i just want you to kinda eliminate that the active repetitive motions that you're doing all the time just for a couple weeks i'm also gon na give you a wrist splint to wear and that should help and i'd like you to take ibuprofen six hundred milligrams every six hours and then i wan na see you back here in the office in two weeks and in that two week period i think we're gon na see if there's need for any other intervention if i need to do more diagnostic testing or if there is a possibly looking at a surgical intervention to release that pressure that's on the nerves in that hand does that sound like a a good plan for you [patient] yeah it sounds like a good first start [doctor] okay okay so i just just off off the record here what kind of what do what do you specialize in landscaping is your company do [patient] mostly like yard work and maintenance flower beds not really designing just up keep [doctor] okay yeah i'm looking for a landscape designer i need somebody to put in some elaborate walkways back through the backyard so yeah we can do stuff like that i mean if you have an idea what you want i think that's easy [patient] okay [doctor] you know if you're looking for like some [patient] backyard elasis rehab remodel that's i mean i suppose we could do we have n't done things like that in a while because we're busy enough with just the up key but it's something to explore [doctor] okay yeah i may have to keep that in mind because i do wan na do some of that so let's listen i'm gon na get my my nurse in here to discharge you do you have any other questions for me before we end this [patient] no i think it's all clear i appreciate it [doctor] okay take care and i'll look forward to see you in two weeks [patient] very good appreciate your time
CHIEF COMPLAINT Left wrist and hand pain. HISTORY OF PRESENT ILLNESS George Lewis is a pleasant 57-year-old male who presents to the clinic today for evaluation of left wrist and hand pain. He reports an onset of a few months ago but denies any specific injury. However, the patient notes he often engages in repetitive motions while performing his work duties. His symptoms are worse at night, and he wakes with numbness in the bilateral hands. He experiences numbness in all fingers, but states it is the most noticeable in the left thumb and index finger. He affirms intermittent numbness in the left little finger. For relief, he shakes his hands upon waking. The patient also experiences weakness in his left hand. He reports he drops objects and explains “I have a hard time feeling it.” MEDICAL HISTORY The patient denies a history of rheumatoid arthritis. SOCIAL HISTORY He works in landscaping. He reports consuming 1 to 2 beers on weekends. REVIEW OF SYSTEMS Musculoskeletal: Reports left wrist and hand pain. Denies right hand pain. Neurological: Reports numbness in bilateral hands and fingers, and left hand weakness. PHYSICAL EXAM NEURO: Decreased sensation in the right thumb and index finger. MSK: Examination of the bilateral hands: Grip strength is less on the left in comparison to the right. Positive Tinel sign bilaterally. ASSESSMENT Bilateral carpal tunnel syndrome. PLAN After reviewing the patient's clinical history and examination today, I have had a lengthy discussion with him regarding treatment options for his current symptoms. I discussed the importance of activity modification and encouraged the patient to limit active repetitive motions while working for the next 2 weeks. I also recommended that he wear a wrist splint to provide increased support. I advised him to take ibuprofen 600 mg every 6 hours. Additionally, I recommended we obtain an EMG of the bilateral upper extremities to evaluate for carpal tunnel syndrome. The patient will follow up with me in 2 weeks when the EMG results are available for review. If at that time his symptoms have not improved with these conservative measures, we will discuss further treatment options including additional diagnostic testing or possible surgical intervention. The patient states he understands and is in agreement with the plan. All questions were answered to the patient's satisfaction. INSTRUCTIONS The patient will follow up with me in 2 weeks.
ACI004
aci
[doctor] hi billy how are you what's been going on the medical assistant told me that you're having some difficulty urinating [patient] yeah yeah i did n't really wan na come in to talk about it's kinda weird but i think probably over the last six months i'm just not peeing right it just does n't seem to be normal [doctor] okay so let's talk a little bit about that now is your is your stream is your urination stream weak [patient] yeah i'd probably say so [doctor] okay and do you feel like you're emptying your bladder fully or do you feel like you still have some urine left in there when you when you finish [patient] most of the times i'm okay but sometimes if i stand there long enough i can kinda go a little bit more so it's taking a while actually to just go to the bathroom [doctor] okay and are you waking up at night to go to the bathroom does it impact your sleep [patient] yeah i try to empty my bladder now right before i go to bed and and not drink anything but i'm still probably getting up three or four times a night to go to the bed [doctor] okay so you're getting up about three or four times a night and and how long has this been going on you said for about six months [patient] yeah six months to like this and it's probably been a little bit worse over the last six months and maybe it's been longer i just did n't want to bring it up [doctor] okay so you think it's been going on longer okay alright now how about have you had any burning when you urinate at all [patient] no it i do n't think it burns [doctor] no burning when you urinate okay and and any other any other issues any problems with your bowels any constipation issues [patient] hmmm no i had diarrhea last week but i think i ate something bad [doctor] okay and ever have you ever had any issues where you had what we call urinary retention where you could n't pee and you needed to have like a catheter inserted [patient] my gosh no [doctor] okay [patient] i'll do that [doctor] alright and have you ever seen a urologist i do n't think so you've been my patient for a while i do n't remember ever sending you but have you ever seen one [patient] i do n't think so [doctor] okay now tell me how are you doing with your with your heart when was the last time you saw doctor moore the cardiologist i know that you had the the stent placed in your right coronary artery about what was that twenty eighteen [patient] yeah sounds about right i think i just saw him in november he said everything was okay [doctor] he said everything was okay alright and so you have n't had any chest pain or shortness of breath you're still walking around doing your activities of daily living are you exercising [patient] kind of [doctor] kind of okay now from what i remember i remember you being a big college football fan are you as excited as i am that georgia beat alabama in the national championships [patient] yeah yeah i'm super excited [doctor] you do n't really seem that excited [patient] get the problem fixed because i have to be able to sit there and watch the whole game [doctor] yeah i really do n't like nick saving i'm so i'm super happy that that the dogs pulled it out [patient] i do n't know if we can do friends anymore [doctor] are you in alabama fan [patient] maybe i'm actually originally not from georgia so [doctor] okay alright well i mean i'm i'm a long horns fan but anyway well i digress let's talk a little bit about your diabetes how are how are you doing with your sugars are you watching your diet [patient] i'm trying to yeah i think they are okay [doctor] okay and are you still taking the metformin [patient] yep [doctor] you are okay alright now i wan na go ahead and just move on to a quick physical exam okay i'm gon na be calling out some of my exam findings and i'm gon na let you know what that means when i'm done okay alright i do have to do a rectal exam i apologize i'm just gon na be calling it out what what i what i appreciate okay so on your heart exam i do appreciate a slight three out of six systolic ejection murmur hurt at the left base on your lung exam your lungs are clear to auscultation bilaterally on your abdominal exam your abdomen is nontender and nondistended i do n't appreciate any masses or any rebound or guarding on your prostate exam i do appreciate an enlarged prostate i do n't appreciate any masses on physical exam so what what does that mean billy so that ultimately means that you know everything looks good you know you have that little heart murmur which i believe you you've had in the past but we're gon na go ahead and look into that you know your prostate seems a little bit enlarged to me on physical exam so let's talk about how we can go about and and remedy that okay so for your first problem of this you know difficulty urinating i wan na go ahead and just order some routine labs i wan na get a a psa that kind of that ultimately kinda looks for prostate cancer issues which i do n't think you have because we did n't really appreciate that on physical exam i wan na go ahead and we can try to start you on what we call flomax zero point four milligrams once a day you should take it at night because it can cause people to get a little bit dizzy if they take it in the morning so i would take it at night and i wan na go ahead and refer you to a urologist just to look into this more so we can go ahead and and get this problem solved for you okay i'm also gon na go ahead and just order some routine blood tests just to make sure that we are not missing anything do you have any questions about that and i wan na go ahead and order a urinalysis and a urine culture [patient] yeah so sounds good have you seen that commercial for that super batter prostate stuff does that work [doctor] well i think the data it's it's i'm not really sure if it works or not i'm not that familiar with it let's just go ahead and stick with flomax and that's why we are gon na refer you to the urologist so that they can go ahead and talk to you about you know the most current treatment options for you okay [patient] alright [doctor] alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that [patient] nope [doctor] okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns [patient] alright when is the urologist gon na call me [doctor] i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week [patient] sounds good [doctor] okay alright well great it was good to see you bye [doctor] i could just hit it and i can just talk and then i'm just
CHIEF COMPLAINT Difficulty urinating. MEDICAL HISTORY Patient reports history of coronary artery disease and diabetes. SURGICAL HISTORY Patient reports undergoing right coronary arter stent placement in 2018 by Dr. Moore. SOCIAL HISTORY Patient reports that he tries to exercise. He is a college football fan. REVIEW OF SYSTEMS Cardiovascular: Denies chest pain or shortness of breath. Gastrointestinal: Denies change in bowel movements. Genitourinary: Reports difficulty urinating. Denies dysuria or urinary retention. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular Slight 3/6 systolic ejection murmur heard at the left base. Gastrointestinal - Examination of Abdomen: Nontender and nondistended. No masses, rebound or guarding. Rectal - Examination: Enlarged prostate appreciated. No masses appreciated. ASSESSMENT AND PLAN 1. Difficulty urinating. - Medical Reasoning: The patient presents today with approximately a 6 month history of difficulty with urination. His prostate also felt slightly enlarged on exam today. - Patient Education and Counseling: The patient was advised that there were no concerning symptoms of prostate cancer appreciated on his physical exam today. - Medical Treatment: We will order routine labs including a PSA to rule out prostate cancer. We will also refer him to a urologist for further evaluation as well as order a urinalysis and urine culture. We will start him on Flomax 0.4 mg once at night to avoid dizziness. 2. Coronary artery disease. - Medical Reasoning: The patient had a 3/6 systolic ejection murmur heard at the left base on exam today. This has been heard on his exams in the past. - Medical Treatment: We will order an echocardiogram to follow up on his murmur. We will also order a lipid panel. He will continue Lipitor 40 mg a day, aspirin and metoprolol. 3. Diabetes. - Medical Reasoning: The patient is currently doing well with his diabetes. - Medical Treatment: We will continue him on metformin 1000 mg twice a day. A hemoglobin A1c will be ordered to see if any medication adjustments are needed. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS He will follow up in 3 to 4 weeks and is advised to call or message me in the patient portal if he has any concerns.
ACI005
aci
[doctor] hi russell how are you what's been going on [patient] well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days [doctor] i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist okay well does the pain move or or or go anywhere or does it stay right in that same spot yeah it feels like it goes to my lower abdomen in into my groin okay and is the pain constant or does it come and go it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position okay and do you notice any any pain when you urinate or when you pee [patient] yeah it kinda burns a little bit [doctor] okay do you notice any blood i do n't think there is any you know frank blood but the urine looks a little dark sometimes okay and what have you taken for the pain i have taken some tylenol but it has n't really helped okay and do you have any nausea vomiting any fever chills i feel nauseated but i'm not vomiting okay is anyone in your in your family had kidney stones yes my father had them and have you had kidney stones before yeah so i've i've had them but i've been able to pass them but this is taking a lot longer okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay [patient] okay [doctor] okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay okay sounds good thank you
CHIEF COMPLAINT Right-sided abdominal pain MEDICAL HISTORY Patient reports history of kidney stones. FAMILY HISTORY Patient reports his father has a history of kidney stones. MEDICATIONS Patient reports use of Tylenol. REVIEW OF SYSTEMS Gastrointestinal: Reports right-sided abdominal pain and nausea. Denies vomiting Genitourinary: Reports dysuria and dark colored urine. Denies hematuria. PHYSICAL EXAM Gastrointestinal - Examination of Abdomen: No masses or tenderness to palpation. No rebound or guarding. No peritoneal signs. Positive CVA tenderness on the right flank. RESULTS Previous CT scan of the abdomen ordered by the patient's PCP is reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter. There is no evidence of hydronephrosis. ASSESSMENT AND PLAN 1. Acute nephrolithiasis. - Medical Reasoning: The patient presents with complaints of right-sided abdominal pain. His previous CT scan was reviewed and demonstrates a 0.5 cm kidney stone located in the proximal right ureter without evidence of hydronephrosis. - Medical Treatment: I have recommended that he push fluids in order to help facilitate urination to help pass the stone. He will be provided with a strainer to allow us to potentially test the stone if he is able to pass it. I have also prescribed oxycodone 5 mg every 6 to 8 hours as needed for pain. He can continue to alternate oxycodone with Tylenol. A basic metabolic panel, urinalysis, and urine culture will also be ordered. INSTRUCTIONS He will follow up in 1 to 2 weeks. If he is still having symptoms at that time, we will discuss further treatment such as lithotripsy or ureteroscopy. He is to contact me if he is having worsening symptoms over the next week.
ACI006
aci
[doctor] so beverly is a 53 -year-old female with a recent diagnosis of stage three non-small cell lung cancer who presents for follow-up during neo agit chemotherapy she was diagnosed with a four . four centimeter left upper lobe nodule biopsy was positive for adenocarcinoma molecular testing is pending at this time alright hello beverly how are you [patient] i'm good today [doctor] you're good today yeah you've been going through a lot lately i know you just had your treatment how how are your symptoms [patient] my symptoms are pretty good today i just kind of have a minimal cough and a sore throat [doctor] okay [patient] but that's all i'm feeling today [doctor] okay and how about fatigue have you been feeling more tired [patient] yes a little bit [doctor] okay and how about any nausea or vomiting [patient] no not as of today [doctor] okay and i know you were mentioning a cough before how is it as far as walking are you having any shortness of breath [patient] i have n't noticed any shortness of breath it just kind of seems to be a lingering kind of light dry cough [doctor] cough okay is it any mucus with it or is it a dry cough [patient] more dry [doctor] a dry cough okay and tell me more about this sore throat [patient] this kind of seems to be persistent comes and goes it will be worse sometimes and then others it feels better trying to drink lots of fluids [doctor] okay [patient] to see if it can it you know the dry coughing if it's part of that or what i can do [doctor] okay and when you mention drinking and eating is do you feel like anything is getting stuck there [patient] no i do n't feel like anything is getting stuck right now and i have n't been i have been eating but not as much as i normally would [doctor] okay okay alright and how are you doing as far as like just emotionally and mentally how are you doing i'm just talking a little bit about your support systems [patient] the nursing staff and the office has been very good to help you know with anything that i need as far as support so just since we are just getting started so far on the journey i do feel like i have support and mentally you know still feel strong [doctor] okay and how about with family or friends have you been able to turn to anyone [patient] i do have good family members that have been supportive and they have come to my treatment with me [doctor] okay excellent excellent and so right now you're on a combination of two different chemotherapies the cisplatin as well as the etoposide and you had your last treatment just a few days ago but you're saying right now you've been able to tolerate the nausea and the fatigue [patient] yes i have n't had any nausea but you know just slight fatigue it does n't seem to be overwhelming [doctor] okay okay so we are gon na go ahead if it's okay with you and start your physical exam reviewing your vitals so vitals look good especially your oxygen especially with the chemotherapy you've been getting and the cough so your oxygen looks good so i'm happy with that so now i'm just examining your neck especially with your sore throat and i do n't appreciate any cervical lymphadenopathy and also no supraclavicular adenopathy listening to your heart you have a nice regular rate and rhythm with no murmurs that i appreciate now on your lung exam when you're taking some deep breaths i do notice some crackles in your lungs bilaterally and what that means is there is there is some faint sounds that i'm hearing which could represent some fluid there so on looking at your skin exam on your chest you do have some erythema on the anterior side of the chest on the left side and this could be related to the radiation so on your lower extremities i appreciate no edema and everything else looks good and thank you i know you did a chest x-ray before coming in so on your results for the chest x-ray it does look like you have some mild radiation pneumonitis which basically means some inflammation of the lungs most likely due to the radiation so what does this all mean so for your assessment and plan so for the first diagnosis the first problem of the lung cancer so what we're gon na do is we're gon na continue with the current regimen of your chemotherapy of the cisplatin and etoposide and the etoposide and we're gon na continue with your current dose of radiation at forty five gray and when that's complete we will repeat some imaging and hopefully you know the tumor will shrink down enough that we can remove it surgically okay for problem number two so the radiation pneumonitis so that's what causing that cough as well as some of the shortness of breath i know you're not experiencing it much now so what i'm gon na do for that is actually gon na prescribe you a low dose of prednisone and so that's an will help with the inflammation i'm gon na give you forty milligrams daily for five days and so hopefully that will help reduce the inflammation and so that you can continue with the radiation okay how does that sound so far [patient] that sounds great thank you [doctor] okay and then lastly for the painful swallowing that you're having so the inflammation you're having it not only in your lungs but it also in your esophagus as well so what i'm gon na do is prescribe you you're taking the the prednisone i'm also gon na give you a lidocaine swish and swallow and you can do that four times a day and so that will be able to help you so you can eat immediately after taking it and it can also help so that you can continue to take food and fluids prevent dehydration and any further weight loss [patient] great [doctor] okay any questions for me [patient] i do n't believe so at this time [doctor] okay alright so i'll see you at your next visit [patient] great thank you [doctor] you're welcome and so now just
CHIEF COMPLAINT Follow up of stage III non-small cell lung cancer. MEDICAL HISTORY Patient reports history of stage III non-small cell lung cancer. SOCIAL HISTORY Patient reports having a good family support system and that some of her family has accompanied her to her chemotherapy sessions. MEDICATIONS Patient reports she is currently receiving chemotherapy treatment consisting of Cisplatin and etoposide. REVIEW OF SYSTEMS Constitutional: Reports fatigue and decrease in appetite. HENT: Reports sore throat. Denies dysphagia. Respiratory: Reports dry cough. Denies shortness of breath. Gastrointestinal: Denies nausea or vomiting VITALS Vitals are within normal limits including oxygen saturation. PHYSICAL EXAM Neck No cervical lymphadenopathy or supraclavicular adenopathy. Respiratory - Auscultation of Lungs: Crackles heard bilaterally. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No murmurs. Musculoskeletal - Examination: No edema. Integumentary - Erythema noted on the anterior side of the chest on the left side possibly related to radiation. Hematology/Lymphatic/Immunology - Palpation: No enlarged lymph nodes. RESULTS Chest x-ray is reviewed and demonstrates mild radiation pneumonitis. ASSESSMENT AND PLAN 1. Stage III non-small cell lung cancer. - Medical Reasoning: The patient has a recent diagnosis of stage III non-small cell lung cancer. Biopsy was positive for adenocarcinoma. Molecular testing is pending at this time. - Medical Treatment: We are going to continue with the current regimen of combination chemotherapy consisting of Cisplatin and etoposide. We are also going to continue with her current dose of radiation at 45 Gy. Once this is complete, we will obtain repeat imaging in hopes that the tumor will decrease in size enough for surgical removal. 2. Radiation pneumonitis. - Medical Reasoning: The patient is experiencing a persistent dry cough. Recent x-rays are reviewed and demonstrated evidence of mild radiation pneumonitis. - Patient Education and Counseling: We discussed the etiology of her dry cough is from her mild radiation pneumonitis. - Medical Treatment: A prescription of prednisone 40 mg daily for 5 days is provided to help with her inflammation. 3. Painful swallowing. - Medical Reasoning: The patient is experiencing painful swallowing secondary to inflammation of the esophagus. - Patient Education and Counseling: We discussed the etiology of her painful swallowing and that a lidocaine viscous solution will be beneficial in preventing dehydration and any further weight loss. - Medical Treatment: A lidocaine viscous solution was provided to be performed 4 times daily. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will return to clinic at her next scheduled follow up.
ACI011
aci
[doctor] hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that [patient] yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some burning and some stinging and looked down and saw a blister i did n't think too much of it because it was on the pad of the bottom of my foot around my heel and i just had been walking on the front part of my foot i started to notice a foul smell and my wife mentioned something to me the other day and i noticed my dog was also smelling my socks a lot and so we looked and saw that the blister had become unroofed or the the top part of the skin of the blister became undone and then underneath it was just this really thick soft mushy skin that had a bad smell with some yellow drainage and so and barbara called the primary care doctor who then got me in to see you he started me on some antibiotics about six days ago and i never had any nausea or vomiting but my wife checked my temperature it was about ninety nine point seven and then at one point i had to put on an extra blanket in bed because i had some chills and when i started the antibiotics it started to feel pretty good but we've now noticed that it has turned black around the outside of the wound and i'm getting some cramping in my calf muscle as well and so there was a red streak also that was coming up the front part of my my ankle along the inside portion of my calf muscle and it's super super hot and so they wanted me to take a have have you look at it [doctor] okay thank you for sharing that history with me and did you complete that course of antibiotics [patient] i think he called in ten days' worth and i'm on day six or seven right now i know i've got about two or three days left [doctor] okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now [patient] yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point [doctor] okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that [patient] yeah my my a1c is six point seven it's pretty well controlled [doctor] okay [patient] i used to be on an insulin pump and i had an a1c that at one point was like thirteen but we worked with an endocrinologist to get it down to where it's at now i've been six point seven for probably two years now and i rarely have a blood sugar that goes over two hundred i check two or three times a day if i feel weird i'll check it again but i noticed my sugars have probably been trending in the three to four hundreds the last two weeks and then i had one spike at one point at like five or six hundred that got our attention and i think that's also what made my wife call the primary care doc [doctor] okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park [patient] yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now [doctor] absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there [patient] i do n't feel that right there [doctor] okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure [patient] no not really so you're gon na continue the antibiotics that i'm on and possibly extend or call in a new antibiotic depending on the culture [doctor] correct [patient] if i heard [doctor] yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy [patient] okay sounds good [doctor] alright
CHIEF COMPLAINT Non-healing ulcer on his right foot. HISTORY OF PRESENT ILLNESS Nicholas Gutierrez is a pleasant 45-year-old male who presents to the clinic today for the evaluation of a non-healing ulcer on his right foot. The patient was referred from his primary care physician. The onset of his pain began 6 weeks ago, after wearing a pair of shoes that were too tight. Today, he describes a burning, stinging, and throbbing sensation. The patient reports a blister on the pad of the plantar aspect of his foot around his heel. He explains that he has been ambulating on the anterior aspect of his foot. He explains that the top part of the skin of the blister detached, which revealed a thick, soft, mushy skin associated with unpleasant smell and yellow drainage. The patient called his primary care physician, who referred him to our office. He was prescribed a 10-day course of antibiotics approximately 6 days ago. He experienced chills and a fever of 99.7 degrees Fahrenheit. The patient denies any nausea or vomiting. He states that when he started the antibiotics, his foot began to feel pretty good. However, he has now noticed that his foot has turned black around the outside of the wound, and he is experiencing cramping in his calf muscle as well. He also reports a burning red streak that was coming up the front part of his ankle along the inside portion of his calf muscle. While palpating his calf, he has noted stiffness in the muscle that is now up to the patella. The patient reports that he has been coughing a lot over the last 2 days. He has experienced shortness of breath with ambulation around the house. He reports that he purchases new diabetic shoes yearly and changes the inserts every 3 to 4 months. The patient is diabetic and has diabetic neuropathy. He explains that his blood sugar has been trending in the 300 to 400's over the last 2 weeks. At one point, he had a blood sugar spike to either 500 or 600. He states that his last hemoglobin A1c was 6.7, which has been his average for approximately 2 years. The patient checks his blood sugar 2 to 3 times per day and rarely has a blood sugar that goes over 200. He explains that he used to be on an insulin pump and had an A1c that at one point was 13. He states that he worked with an endocrinologist to get it down to where it is now. MEDICAL HISTORY The patient reports a history of diabetic neuropathy. SOCIAL HISTORY The patient enjoys hiking. REVIEW OF SYSTEMS Constitutional: Reports subjective fever and chills Respiratory: Reports cough and shortness of breath with ambulation. Gastrointestinal: Denies nausea and vomiting. Musculoskeletal: Reports right foot pain and right calf cramping. Skin: Reports right foot ulcer with yellow foul smelling drainage, and red streaking coming up the front part of his ankle along the inside portion of his calf muscle. VITALS Temperature is slightly elevated. Vitals are otherwise good. PHYSICAL EXAM CV: Edema and pain in calf. Bilateral palpable femoral and papiteal pulses are present. I do not recognize a palpable dorsalis pedis or posterior tibial pulse; however, they are present via Doppler. MSK: Examination of the right foot: The necrotic wound on his heel is present. It is approximately 2 cm x 2 cm. I do recognize the sloughing of the tissue, as well as what looks like cellulitis around the area, and erythema. An odor is present from the wound. I do not appreciate any bony exposure now. No pain to palpation in the effected area. RESULTS 3 views of the right foot were taken today. These reveal no evidence of osteomyelitis or infection. ASSESSMENT Right non-healing diabetic foot ulcer. Diabetes. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to his current symptoms. I have explained to him that I do not see any evidence of osteomyelitis. I am concerned about the redness that is moving up his leg, as well as the swelling, and pain that he has in his calf. I have recommended that we obtain a venous ultrasound to check his blood supply for the wound. I have also recommended that we perform a debridement of the wound today. We may have to obtain a culture and look at different antibiotic therapy. I am recommending that he continue with antibiotics that his primary care physician prescribed. In regard to his diabetes, I have advised him to follow up with his endocrinologist to ensure that we do continue to keep his hemoglobin A1c below 7. We will need to closely monitor his blood sugar since we are going to be doing some medication therapy with antibiotics and potentially some other medications depending on the culture results. INSTRUCTIONS The patient will follow up with me in 7 days to check on his progress.
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[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 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'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'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 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
HISTORY OF PRESENT ILLNESS Anna Diaz is a pleasant 29-year-old female who presents to the clinic today for the evaluation of right-sided back pain. For approximately 1 week, the patient has been experiencing constant right-sided back pain that radiates down to her lower right side, as well as hematuria and nausea. Her primary care physician was concerned for possible kidney stones and subsequently referred her here for further evaluation. She denies any pain with urination or vomiting, but admits that she has likely not been drinking enough water. The only treatment she has tried so far is ibuprofen with minimal pain relief. Although she denies any personal history of kidney stones prior to this occurrence, she explains that her father has had kidney stones in the past. REVIEW OF SYSTEMS Constitutional: Negative for fever. Gastrointestinal: Positive for nausea. Negative for vomiting. Genitourinary: Positive for hematuria VITALS Vitals are normal. Blood pressure is normal. Heart rate is normal. PHYSICAL EXAM GI/GU: Mild pain and tenderness to palpation of the abdomen. No rebound or guarding. There is CVA located near her flank with tenderness on the right. RESULTS CT scan of the abdomen was reviewed today and revealed a kidney stone measuring 0.5 cm in size, located in the proximal right ureter. There is no evidence of hydronephrosis. 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. INSTRUCTIONS Follow up in 2 weeks.
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[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'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 passes 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
CHIEF COMPLAINT Kidney stones. HISTORY OF PRESENT ILLNESS Mason Ward is a pleasant 80-year-old male who presents to the clinic today for the evaluation of kidney stones. The patient was referred from his primary care physician. The onset of his pain began 1 week ago when he was in his barn moving hay when he had a sudden onset of right back pain. The patient initially thought his pain was due to throwing hay; however, he broke out into a sweat and became nauseated. He was seen by his primary care physician, who ordered a CT scan and told him that he had a kidney stone. He denies having kidney stones before, but states that his father has a history of kidney stones in the past. He explains that when he had pain, which has now resolved, it would radiate almost to his groin. The patient describes the pain as intermittent after he found out it was a kidney stone. He explains that he has been straining his urine, but has not seen anything. He denies any hematuria. REVIEW OF SYSTEMS Musculoskeletal: Reports right back pain. VITALS Vitals look good, blood pressure and hear rate are within normal limits. Temperature is within normal limits. PHYSICAL EXAM MSK: Examination of the abdomen: No pain with palpation of the abdomen. No rebound or guarding. There is CVA tenderness on the right side. RESULTS The CT scan of the abdomen revealed a stone that is measuring 0.5 cm located in the proximal right ureter. There is no evidence of hydronephrosis. 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. INSTRUCTIONS The patient will follow up with me in 1 to 2 weeks to check on his progress. If his symptoms have not improved, we will discuss further treatment options including lithotripsy.
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[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 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 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 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
CHIEF COMPLAINT Right knee pain. MEDICAL HISTORY The patient has a history of diabetes. She has been doing pretty good with her diet. She states that she forgets to check her sugars quite a bit. REVIEW OF SYSTEMS Musculoskeletal: Reports right knee pain and swelling. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular No murmurs, gallops. Musculoskeletal - Examination of the right knee: Some swelling present. - Palpation: Some pain to palpation on the medial aspect of the right knee, and a little bit of pain on the lateral aspect of the right knee. - Range of Motion: Limited range of motion as well as pain on both flexion and extension of the knee. - Special Testing: McMurray's Test: Negative. 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. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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[doctor] hey philip good to see you today so take a look here at my notes i see you're coming in for some right knee pain and you have a past medical history of hypertension and we will take a look at that so can you tell me what happened to your knee [patient] yeah i was you know i was just doing some work on my property and i accidentally slipped and fell down and i just still having some knee issues [doctor] okay well that that's not good do you [patient] no [doctor] what part of your knee would you say hurts [patient] i would just say you know the it it you know it basically when i when i'm flexing my knee when i'm moving it up and down and i put pressure on it [doctor] alright did you hear a pop or anything like that [patient] i did feel something pop yes [doctor] okay and did it was it swollen afterwards or is it looks a little bit swollen right now [patient] yeah little bit swollen yeah [doctor] okay so so far have you taken anything for the pain [patient] just taking some ibuprofen just for some swelling [doctor] okay that's it what would you say your pain score is a out of ten with ten being the worst pain you ever felt [patient] i would say that when i'm stationary i do n't really feel a lot of pain but if i start doing some mobility i would say probably a four five [doctor] about a four okay and how long ago did you say this was is this happened this injury [patient] it's been a week now [doctor] a week okay alright alright so we will take a look i'll do a physical exam of your knee in a second but i do want to check up you do have a past medical history of hypertension i'm seeing here you're on twenty milligrams of lisinopril when you came in today your blood pressure was a little bit high it was one fifty over seventy so have you been taking your medications regularly [patient] yes i have [doctor] okay so you might have a little white coat syndrome i know some of my patients definitely do have that so what about your diet i know we talked a little bit before about you reducing your sodium intake to about twenty three hundred milligrams per per day i know you were during the pandemic your diet got out of little bit out of control so how have you been doing how have you been doing with that [patient] i definitely need some help there i have not have not made some some changes [doctor] okay yeah we definitely need to get you to lower that salt intake get your diet a little bit better because the hope is to get you off that medication and get your blood pressure to a manageable level okay so we yeah we definitely can talk about that alright so lem me take a look at your knee i'll do a quick physical exam on you and before i do just want to make sure you're not having any chest pain today [patient] no [doctor] are you any belly pain [patient] no [doctor] no shortness of breath just wan na make sure [patient] no [doctor] okay so i'm just gon na listen to your lungs here your lungs are clear bilaterally i do n't hear any wheezes or crackles listen to your heart so on your heart exam i do still hear that grade two out of six systolic ejection murmur and you already had that and so we we knew about that already so lem me look at your knee here so when i press here on the inside of your knee does that hurt [patient] a little bit [doctor] little bit how about when i press on the outs the outside gon na press on the outside is that painful [patient] no [doctor] no alright so i'm gon na have you flex your knee is that painful [patient] yeah that's uncomfortable [doctor] that's uncomfortable and extend it so that's painful [patient] yeah yes [doctor] okay so on your knee exam i see that you do have pain to palpation of the medial aspect of your right knee you have some pain with flexion extension i also identify some edema around the knee and some effusion you have a little bit of fluid in there as well so prior to coming in we did do an x-ray of that right knee and luckily you did n't break anything so there is no fractures no bony abnormalities so let's talk a little bit about my assessment and plan for you so you have what we call a mcl strain so a medial collateral ligament strain so when you fell i think you twisted a little bit and so it irritated you strained that that ligament there so for that what we can do for you first i'm gon na prescribe you some ibuprofen eight hundred milligrams and you can take that twice a day and that's gon na help you with that swelling and that pain that you currently do have i'm also gon na put you in a a knee brace just to try and support those muscles to allow it to heal and then i want you to ice the knee you can do that for twenty minutes at a time for three to four times a day that should also help with the the swelling of your knee for your hypertension now i'm gon na keep you on that twenty of lisinopril okay because you are taking it and you you're doing pretty good with it i also want to get you a referral to nutrition just to try to help you with that diet you know because right now you are your diet is little bit out of control so we just need to rain you in a little bit and hopefully you know with their help we can eventually get you off that lisinopril alright so do you have any questions for me [patient] do i need to elevate my leg or stay off my leg or [doctor] yeah i would yeah you can elevate your leg stay off your stay off your leg you know if you have any kids have them work out in the yard instead of you just to to for a couple of weeks it's a good thing if you want to do that [patient] tell him this doctor's order [doctor] tell definitely tell him his doctor tell him i said it [patient] alright do you have any other questions no that's it i appreciate you seeing me [doctor] alright so my nurse will be in with the those orders and we will see you next time
CHIEF COMPLAINT Right knee pain. REVIEW OF SYSTEMS Cardiovascular: Denies chest pain. Respiratory: Denies shortness of breath. Gastrointestinal: Denies abdominal pain. Musculoskeletal: Reports right knee pain. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. No wheezes. Cardiovascular - Auscultation of Heart: Grade 2/6 systolic ejection murmur. Some edema and effusion noted around the right knee. Musculoskeletal - Examination: Right knee - Palpation: Pain to palpation of the medial aspect. No pain to palpation of the lateral aspect. - ROM: Pain with flexion and extension. -Some effusion noted around the right knee. RESULTS X-rays of the right knee were taken. These show no fractures or bony abnormalities. ASSESSMENT AND PLAN 1. Right knee MCL strain. - Medical Reasoning: Based on the physical examination findings, the patient has a MCL strain of the right knee. - Medical Treatment: I have prescribed ibuprofen 800 mg twice a day. I will also place him in a knee brace. I advised him to ice the knee for 20 minutes at a time for 3 to 4 times a day. The patient was instructed to elevate his leg as needed and avoid strenuous activities for 2-3 weeks. 2. Hypertension. - Medical Treatment: The patient will continue lisinopril 20 mg daily. I have also provided a referral to see a nutritionist for dietary changes. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
ACI027
aci
[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 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 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 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 think the blood pressure's okay [doctor] okay [patient] i have n't had any real problems there 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'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 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
CHIEF COMPLAINT Back pain evaluation. MEDICAL HISTORY The patient has a history of diabetes, hypertension, and high cholesterol. SURGICAL HISTORY He denies previous back surgeries. MEDICATIONS The patient currently utilizes metformin 500 mg twice daily and Norvasc. REVIEW OF SYSTEMS Cardiovascular: Reports ankle swelling. Musculoskeletal: Reports lower back pain. Neurological: Reports tingling in left leg. Denies weakness or numbness in legs, or loss of bowl or bladder function. PHYSICAL EXAM Neurological - Orientation: Alert and oriented x3. Cranial nerves grossly intact. Normal gait. Neck - General Examination: No JVD. No bruits. Respiratory - Auscultation of Lungs: No wheezes, rales. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. 2/6 systolic ejection murmur. Otherwise, regular rate and rhythm. Musculoskeletal - Examination: Tenderness on the left paraspinal area. Straight leg raise test is negative. Reflexes are normal. 1+ nonpitting edema of lower extremities. No calf tenderness. Negative Homan's sign. 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. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 2 weeks.
ACI028
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[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
CHIEF COMPLAINT New patient evaluation of newly diagnosed ovarian cancer. FAMILY HISTORY The patient was adopted and has no knowledge of any family history. REVIEW OF SYSTEMS Constitutional: Reports unintentional weight loss Gastrointestinal: Reports abdominal pain and constipation. Denies vomiting. Genitourinary: Reports abnormal vaginal bleeding. Denies urinary issues. Psychiatric: Reports depression PHYSICAL EXAM Gastrointestinal - Examination of Abdomen: There is slight tenderness to palpation of the left lower quadrant. No rebounding or guarding. Pelvic - Examination: There are no external lesions on the labia. The vaginal vault is within normal limits. The cervix is pink without lesions. On bimanual exam, I appreciate a left adnexal mass. No masses on the right. RESULTS CT scan of the abdomen was reviewed and demonstrated a 3 cm left ovarian mass with associated localized lymph node involvement. There is no evidence of gross peritoneal or metastatic disease. 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. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
ACI030
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[doctor] alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened [patient] well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then all of a sudden i'm here [doctor] hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath [patient] i did but i did n't think anything of it [doctor] sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on [patient] i have but i miss them every year and then so i think today i took one [doctor] okay alright yeah i have you on bumex cozaar and norvasc does that sound right [patient] i guess so that sounds about right [doctor] alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that [patient] i've just been eating anything honestly i try to watch it here and there but to tell you the truth i'd looks i was eating [doctor] yeah i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or [patient] little bit of everything here and there i do lot of chips [doctor] sure [patient] they're pretty good i guess they're salty even though the light salt ones but [doctor] mm-hmm [patient] kinda whatever i can get my hands on really [doctor] okay alright how are you feeling right now [patient] i'm doing a little okay i guess i'm just out of breath a little bit but it's nothing i ca n't handle [doctor] sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those [patient] no i have n't got one yet i know i needed to get one [doctor] yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately [patient] just like i said when i was walking outside it helped a little bit but again i just walked it off [doctor] sure any problems sleeping [patient] no i sleep like a rock [doctor] good good to hear have you had any chest pain [patient] slightly here or there but i thought it was just heartburn [doctor] sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that [patient] i've been pretty good on it very once every week maybe just one [doctor] okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay [patient] that sounds good document [doctor] awesome weigh yourself daily do you have a scale at home [patient] no but i can get one [doctor] okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good [patient] that sounds good to me [doctor] great okay david do you have any other questions [patient] no other questions at this time just i guess i just need to make sure to take my medication on time that's about it [doctor] yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well [patient] i will do my best [doctor] alright thanks hope you feel better [patient] thank you
CHIEF COMPLAINT Follow up. SOCIAL HISTORY The patient has been trying to limit his tobacco use for 2 years. He reports smoking once every week. MEDICATIONS Bumex 2 mg once daily. Cozaar 100 mg daily. Norvasc 5 mg once daily. REVIEW OF SYSTEMS Constitutional: Denies problems sleeping. Cardiovascular: Reports chest pain. Respiratory: Reports shortness of breath. Musculoskeletal: Reports bilateral ankle swelling. VITALS Blood pressure is 128/72 mm Hg. Other vital signs are within normal limits. PHYSICAL EXAM Neck - General Examination: No JVD Respiratory - Auscultation of Lungs: Clear bilaterally. Cardiovascular - Auscultation of Heart: 2/6 stable systolic ejection murmur Musculoskeletal - Examination: Lower extremities show trace edema. RESULTS An echocardiogram, obtained at an outside facility, was reviewed today. It demonstrates a preserved ejection fraction of 55%. Normal diastolic filling. Mild to moderate mitral regurgitation. ASSESSMENT AND PLAN 1. CHF. - Medical Reasoning: The patient’s recent epsiode resulting in the emergency room visit was likely caused by his dietary indiscretion and uncontrolled hypertension that we have been monitoring. - Patient Education and Counseling: I reviewed the echocardiogram results with the patient and discussed the importance of following dietary restrictions. I encouraged the patient to take his medication on a consistent basis. I advised him to purchase a scale to weigh himself daily. - Medical Treatment: He will continue Bumex 2 mg once daily. He was provided with a referral to a nutritionist in consultation for further assistance with his dietary requirements to lower his sodium intake. 2. Hypertension. - Medical Reasoning: This is currently uncontrolled. - Patient Education and Counseling: I explained the importance of taking his medication on a daily basis. I encouraged the patient to purchase a blood pressure cuff and track his blood pressures. - Medical Treatment: He will continue Cozaar 100 mg daily as well as the Norvasc 5 mg once daily. I will order a renal artery ultrasound for further evaluation. 3. Systolic ejection murmur. - Medical Reasoning. Stable. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient was instructed to call me if he gains 3 pounds in 2 days.
ACI031
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[doctor] hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee [patient] yes i hurt my knee when i was skiing two weeks ago [doctor] okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury [patient] so i was flying down this black diamond you know like i like to do [doctor] yes [patient] and this kid who was going faster than me spent by me so then i tried to speed past them and then i ran into a tree and twisted my knee [doctor] so we were downhill skiing racing at this point okay is it your left or your right knee [patient] it's my right [doctor] okay and does it hurt on the inside or the outside [patient] the inside [doctor] okay so the medial aspect of the right knee when you fell did you hear a pop [patient] i did yes [doctor] okay alright [patient] i think that was my left knee [doctor] okay okay alright so we got we got ta pick one if it if it [patient] i'm just trying to be real [doctor] no [patient] what happens in the in a real [doctor] a hundred percent so how about this right now you're like i what i'm hearing is that you're experiencing bilateral knee pain like both of your knees hurt but i'm assuming that like your right knee hurts more is that correct [patient] yeah my left knee does n't really hurt [doctor] uh uh [patient] that's the one that popped it the left knee just feels unstable but my right knee hurts [doctor] gotcha gotcha okay yeah i think hmmm alright so we're gon na we're gon na go ahead and look at this sort of but on a scale of one to ten how severe is your pain [patient] it's a seven [doctor] okay that's pretty bad alright and does it has it been increasing or like rapidly or slowly over the last few days [patient] it's been slow [doctor] okay alright [patient] but sometimes it gets to an eleven [doctor] okay what would do you know if you are doing something that would cause it to be an eleven are you back on your ski's [patient] no i ca n't ski [doctor] okay [patient] usually when i walk my dog [doctor] okay does it hurt more when you walk for longer periods of time [patient] yes [doctor] okay how long does the pain last [patient] for as long as my walk is and i do n't sometimes i walk five minutes kinda depends on the wind [doctor] okay alright [patient] sometimes i walk there is [doctor] okay alright have you done anything to help with the pain [patient] well i wear a brace and i have used a lot of thc cream on it [doctor] okay alright thc cream is an interesting choice but do you think that's been helpful [patient] yes [doctor] alright have you taken [patient] reasons [doctor] not a problem have you taken any medications [patient] no just gummies [doctor] okay like vitamins or more thc [patient] kind of like thc gummies [doctor] thc gummies [patient] my grandma gave them to me [doctor] thc gummies from grandma that's an excellent grandmother that you have okay have you noticed any swelling stiffness tenderness [patient] yeah i get a lot of swelling and it really is it's very stiff in the morning until i get walking [doctor] okay alright and then have you had any hospitalizations or surgeries in the past [patient] well i had surgery on my right knee before [doctor] okay so you've had surgery before alright do you remember what kind of surgery [patient] i do n't know they told me they reconstructed the whole thing i was fourteen i was a really good gymnast back then really good [doctor] okay [patient] and i was doing a back summer salt and i felt a pop then and then since that time i've really had problems with my knee [doctor] uh uh [patient] but you know the athlete that i am i can still really ski very well so i just kept going [doctor] okay [patient] and i'm really tough my pain tolerance is very high [doctor] okay okay okay how so do you have any other exercises that i might wan na know about outside of intense gym and ski events [patient] no i think that's about it [doctor] okay and how frequently do you normally ski [patient] i ski probably three times a week [doctor] okay and then are you on any medications at this time other than the thc [patient] no [doctor] okay alright what [patient] nothing no [doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and start my examination i'm just gon na call it out for the sake of being able to document it appropriately and you or just just let me know if you want me to explain anything further so with your knee i know that you said it hurts on the right inside a lot right so when i press on the inside of your knee does that hurt [patient] yes [doctor] okay and when i press on the outside of your left of your right knee sorry does that hurt [patient] no [doctor] okay alright so when i move your your kneecap does that hurt [patient] no it kinda makes a shooting pain down to my ankle though [doctor] okay [patient] but it does n't hurt my knee [doctor] okay so does the pain radiate frequently [patient] no [doctor] okay [patient] i've never really noticed it just messed with my kneecap [doctor] okay alright on your skin exam i do appreciate some mild swelling and bruising that's really interesting since it's been two weeks with your knee are you able to bend it [patient] yes [doctor] okay and then when you walked in on your gait i think i think i did appreciate a slight limp are you i think you are you are protecting one of your knees does that sound familiar [patient] yeah i waddle pretty pretty good now [doctor] okay alright and when you move your knee away from your body you're bending like your you're pulling it towards me does that hurt [patient] yes [doctor] okay and then when you pull your knee back towards you does that hurt [patient] no [doctor] alright so pain on dorsiflexion but not on plantar flexion plantar flexion okay alright so what we are gon na do right now i think i'm gon na look at your x-rays but when i when i look at the results of your x-ray i do not appreciate any fracture what i am noticing is the development of a little bit of arthritis and that could explain like why you say that your joints hurt a bit more during like windy weather and what not so this is what we're gon na do for my assessment and plan right the first thing is i think you have a strain of your posterior cruciate ligament what that means is what that will mean for you though is that we are gon na continue to brace your right knee that's gon na hopefully take off some of the stress that you might be putting on it especially since you're limping i am going to recommend you for physical therapy i think it would be an i think it's a good idea to maybe start three times a week to get your strength back into your knee i would recommend not skiing or doing any gymnastics for now and i think that physical therapy will really help considering the injury that you had when you were fourteen i'm gon na prescribe you some medications i do n't necessarily recommend consuming gummies at the same time but the medications i'm gon na give you are gon na be meloxicam fifteen milligrams you're gon na take that once a day that will help with like the swelling and the bruising i'm also gon na prescribe you just like a higher strength nsaid so ibuprofen eight hundred milligrams a day you can take that twice a day as needed for your left knee i think you are i think you just kind of like strength a little bit but like not enough to necessarily require any kind of like medication or bracing i think you just take it easy on your body i know that you're like very active from what i hear and i think that that's really exciting but i think you might need to listen to your body and give yourself a bit of a break you'll be able to do like several workouts when you go to when you go to physical therapy but you know let the yeah let your therapist be your guide about like what you should and should not be putting your body through does that make sense [patient] yes [doctor] alright do you have any questions right now [patient] no thank you so much [doctor] no problem
CHIEF COMPLAINT Right knee injury. HISTORY OF PRESENT ILLNESS Elizabeth Ross is a pleasant 91-year-old female who presents to the clinic today for the evaluation of a right knee injury. The onset of her pain began 2 weeks ago, when she was downhill skiing. She states she ran into a tree and twisted her right knee. At the time of the injury, she also heard a pop in her left knee, however she denies left knee pain. The patient locates her pain to the medial aspect of her right knee. Currently, her pain level is 7 out of 10, however she notes this can reach an 11 out of 10 at times with prolonged ambulation. The patient states that her pain has been slowly increasing over the last few days. She experiences limping with ambulation. The patient states that her pain lasts for as long as she is ambulating. She denies radiating pain. She also reports constant swelling and stiffness in the morning. Her stiffness will resolve with ambulation. The patient has been wearing a brace and using THC cream, which has been helpful. She denies taking any medications for pain, however she has been utilizing THC gummies, which have been beneficial. The patient has a history of a right knee reconstruction when she was 14 years old. She states that she was a good gymnast at that time. The patient adds that she has had problems with her right knee since that time. She denies any other exercises outside of intense gym and ski events. The patient states that she normally skis 3 times per week. SURGICAL HISTORY The patient reports a history of total right knee reconstruction at the age of 14. MEDICATIONS She denies needing medications. REVIEW OF SYSTEMS Musculoskeletal: Reports right knee pain, swelling, and stiffness. Denies left knee pain. PHYSICAL EXAM MSK: Examination of the right knee: Mild effusion. The patient ambulated with an antalgic gait. Pain with dorsiflexion, but not with plantarflexion. RESULTS 4 views of the right knee were taken. These reveal no evidence of any fractures. There is development of mild arthritis. ASSESSMENT 1. Right knee posterior cruciate ligament strain. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have explained to her that her x-rays did not reveal any signs of a fracture. I have recommended that we treat the patient conservatively with continued bracing. We will initiate formal physical therapy 3 times per week to strengthen her right knee. Additionally, I have prescribed the patient meloxicam 15 mg and ibuprofen 800 mg twice daily as needed. She should discontinue the use of her THC gummies while taking these medications. Regarding her left knee, I do not believe she will need any further medications to treat this. I have advised her to avoid skiing or gymnastics at this time.
ACI032
aci
[patient] alright thanks for coming in today i see on my chart here that you had a bunch of lower respiratory infections so first tell me how are you what's going on [doctor] you know i'm doing better now but you know last week i was really sick and i just have had enough like i was coughing a lot a lot of mucus even had some shortness of breath and even a low-grade fever [patient] wow that is a lot so what did you do for some of those symptoms [doctor] you know i ended up drinking a lot of fluid and taking some robitussin and i actually got better over the weekend and now i'm feeling much better but what concerns me is that i tend to get pneumonia a lot [patient] okay so when you say a lot like how frequently does it occur i would say it seem honestly it seems like it's every month or every other month especially over the past six six months that i just keep getting sick and i usually will end up having to go to my primary care doctor or [doctor] urgent care and i'll get prescribed some antibiotics and one time i actually ended up in the emergency room [patient] wow and how long do your symptoms normally last for [doctor] you know it could be as few as like a couple of days but sometimes it could go even up to a week [patient] mm-hmm you mentioned that you are a farmer did you do you notice that your symptoms occur while doing certain things on the farm [doctor] you know i was trying to think about that and i've been working on the farm for some time but the only thing i can think about is that i've been helping my brother out and i've been started like unloading a lot of hay which i do n't usually do and i wan na say that my symptoms actually start the days that i'm unloading hay [patient] alright do you wear a mask when you're unloading hay [doctor] no i do n't do that [patient] okay [doctor] none of us do [patient] okay yeah so like that your brother does n't either [doctor] no i'm the only one who seems to be getting sick [patient] alright so i know you said you were trying to like help out your brother like what's going on with him [doctor] you know we've just been getting really busy and so he has been working around doing other things so i've just been helping him just cover the extra load [patient] mm-hmm okay alright do you have any other siblings [doctor] yeah there is actually ten of us [patient] wow okay that's that's a lot of siblings [doctor] yeah i'm okay [patient] maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place [doctor] yeah we do n't need to hire any i mean have anyone else this is our family [patient] you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies [doctor] no no i have never had any problems with allergies [patient] okay and do you smoke [doctor] i do n't smoke [patient] do you live with anybody who does [doctor] i do not [patient] okay alright so okay so now i wan na go ahead and do my physical exam i'm gon na call out some of my findings just to make sure that i'm documenting everything and if you have any questions about what it is that i'm saying please feel free to ask okay [doctor] okay [patient] so i reviewed your vitals and you appear to be breathing a little fast your respiratory rate is twenty but but your oxygen is you're satting kind of fine at ninety nine percent on room air so i'm not too worried about that on for on your heart exam i do you have a regular rate and regular rhythm i do not appreciate any murmurs rubs or gallops on your lung exam you know i do you do have some fine rales on your lung exam but no wheezes and on your musculoskeletal exam i do not appreciate any clubbing of your fingers so for your results i did review the results of your chest x-ray and i noticed some round glass opacities so let me tell you a little bit about like my assessment and plan for your first problem of recurrent lung infections your symptoms seem consistent with a condition we call hypersensitivity pneumonitis in your case another name is farmer's lung which you know is appropriate considering your job this could be caused by bacteria and or mold that is found in the hay when you inhale it it leads to an allergic reaction in your lungs this is why your symptoms occur every time you move hay for your current symptoms i'm gon na prescribe you a a course of an oral steroid this will help to decrease the inflammation that is occurring in your lungs i will also be ordering a cat scan of your lungs which will help confirm the diagnosis as as well a pulmonary function test to assess how severe your respiratory impairment is it would be best if you could eliminate your exposure to the hay or prevent further to prevent further damage to your lungs however if you are unable it's very important that you wear a respirator when moving hay around i know that that was a lot of information i think it boils down to pull in more of your siblings to help work around but do you have any questions [doctor] yeah so is this gon na help so i do n't keep getting sick [patient] so ideally what we are doing i think this is the best course of action to deal with the deeper problem right of these infections and to kind of like clear up the pneumonia everything seems to hint on so what we're gon na do is treat your current infection we're going to either prevent you from being around hay or make it so that it's safe for you to be with hay and then we're gon na see like what we need to do moving forward does that help [doctor] okay it does [patient] alright [doctor] thank you [patient] okay no problem [doctor] alright
CHIEF COMPLAINT Recurrent lung infections. SOCIAL HISTORY Patient reports he is a farmer. He denies smoking or living with anyone who smokes. ALLERGIES Patient denies history of seasonal allergies. REVIEW OF SYSTEMS Constitutional: Reports low-grade fever. Respiratory: Reports shortness of breath and productive cough. VITALS Respiratory rate: 20 breaths per minute. Pulse oxygenation: 99 percent on room air. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Some fine rales were noted. Cardiovascular - Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs. Musculoskeletal - Examination: No clubbing. RESULTS X-ray of the chest was reviewed today and shows some round glass opacities. ASSESSMENT AND PLAN 1. Recurrent lung infections. - Medical Reasoning: The patient's symptoms seem consistent with hypersensitivity pneumonitis. He is a farmer and has been moving hay quite frequently recently. - Patient Education and Counseling: The nature of the diagnosis was discussed with the patient. I explained that hypersensitivity pneumonitis could be caused by bacteria and/or mold that is found in the hay. We discussed that when inhaling this, it leads to an allergic reaction in the lungs, which would explain why symptoms occur every time he moves hay. He was advised that it would be best to eliminate his exposure to hay in order to prevent further damage to his lungs, however, if he is unable to do this then it would be recommended that he wear a respirator when working. Questions were invited and answered today. - Medical Treatment: A course of oral steroids were prescribed today to help decrease his lung inflammation. CT of the lungs will also be ordered today to confirm the diagnosis. A pulmonary function test was also ordered to assess the severity of his respiratory impairment. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
ACI035
aci
[doctor] okay [patient] good morning [doctor] good morning thanks doctor doctor cooper i'm i'm you know i'm a little i'm sad to be in here but you know thanks for taking me in i appreciate it [patient] sure absolutely what can i help you with today [doctor] so you know i've been dealing with my asthma and like i tried to join sports but it's really kind of it's getting hard you know and i just wonder if there's something that can be done because i really do like playing water polo [patient] but i'm having difficulty breathing sometimes i've had to like you know stop matches and sit on the side just to kind of like catch my breath and use my inhaler so i was wondering if there was something we could do about it [doctor] and then like i'm kind of a little bit worried i think my mood is getting a little a little worrisome and i wanted to explore like what my options were [patient] okay let's talk about the asthma first so what inhaler are you using now [doctor] i have an albuterol inhaler [patient] okay and when when you're having trouble it's usually just around sports that is it keeping you up at night [doctor] so i do n't really like wake up at night a lot typically like it's sports like you know if i'm doing anything like crazy aerobic or like running or anything i do notice that if any if i'm around smoke i do start coughing a little bit but most of the time it's sports [patient] okay and can you describe a little bit for me what happens [doctor] i start to yeah no so i start to feel like there is like some phlegm building up in my in my throat and i start coughing like my chest gets tight i start wheezing and i just have to sit down or else i'm gon na get like lightheaded too [patient] okay and then when you use your inhaler [doctor] mm-hmm [patient] does it does it alleviate the problem [doctor] so yeah it helps with that like phlegm feeling you know but i still i still have to sit down you know and like breathe and then the thing that i hate about that inhaler is i start getting like shaky is that supposed to be happening [patient] yes that is unfortunately normal and a side effect with the inhaler [doctor] okay [patient] so you use you're using two puffs of the inhaler [doctor] mm-hmm [patient] for the symptoms [doctor] yes [patient] and then you sit down and does it does it get better within about fifteen minutes or so [doctor] yeah yeah it does but you know i had to like step out of the the pool to make that happen i'm hoping that there is something else we can do okay have you ever taken any daily medications for your asthma an inhaler or singulair or anything like that no i just use my inhaler whenever i have an attack [patient] okay so that's something we might wan na consider but how often is it happening [doctor] pretty much every time i do any kind of aerobic workout [patient] okay and outside of physical activity you're not having any problems [doctor] yeah there's that part where like if i'm around somebody who has been smoking a lot or is currently smoking but i usually just step away i do n't even like to be around them you know that makes sense [patient] alright well we will look at that tell me about the mood issues you are having [doctor] yeah so one of the reasons i got into like trying to get into sports is like i feel like you know you you feel a lot more energized and a lot you know happier but like lately i've just been kinda stressed out you know like i have i have like sats that i need to study for i've got like all these ap classes you know there's just it i feel like there's a lot of pressure and you know like i get it but there are times where i'm just like really down and i do n't really know what else i can do [patient] okay that makes sense any any difficulty with focusing or you're having difficulty retaining information or is it more feeling sad not having motivation [doctor] so i think it's like a lot of sadness a lot of like you know i do n't really i kinda feel like you know i do n't really like want to do anything you know my friends will go out and i'll just be like i'd rather be at home i am really tired a lot too [patient] okay alright well let me let me go ahead and check you out [doctor] mm-hmm [patient] and then we can talk a little bit more [doctor] okay [patient] i'm gon na take a listen to your heart and lungs [doctor] mm-hmm [patient] and everything sounds good [doctor] let me take a look at your eyes [patient] mm-hmm and in your ears everything looks okay have you had any problems with allergies you have seasonal allergies or anything like that [doctor] yeah i think so yeah [patient] i do see just a little bit of fluid in the ears [doctor] mm-hmm [patient] and i'm gon na look in your mouth too [doctor] okay [patient] and throat looks fine no tonsils [doctor] mm-hmm [patient] lem me go ahead and have you lay back on the table and i'll take a listen to your stomach [doctor] okay [patient] everything sounds okay i'm gon na feel around just to make sure everything feels normal [doctor] mm-hmm [patient] everything feels fine and i'm gon na check reflexes and they're all normal [doctor] awesome [patient] it's really hard to do with actual patient so in terms of the asthma i think we could try a daily medication since it looks like you might be having a little bit of allergies maybe we can try some singulair [doctor] mm-hmm [patient] and start with that once you are on that daily and you can continue to use the albuterol inhaler those side effects unfortunately you're right it's it's just one of the expected side effects with an albuterol inhaler i would recommend just what you're doing just sit down for a little bit after you take it [doctor] and we will get you started on the singulair probably within about a month you should see a difference so i will have you come back in about six weeks and follow up and see how you're doing with that [patient] in terms of the mood is this new for you [doctor] yeah i think so like when i started this year [patient] and it sounds like related to school expectations and the stress with saps and all of that [doctor] yeah [patient] okay let's consider having you start seeing a therapist i think that would be a good place to start [doctor] mm-hmm [patient] and we will do some screening questionnaires and and then follow up in a couple weeks on that too [doctor] okay alright sounds like a plan okay [patient] thank you
CHIEF COMPLAINT Asthma. MEDICAL HISTORY Patient reports history of asthma. SURGICAL HISTORY Patient reports history of tonsillectomy. SOCIAL HISTORY Patient reports she is a student and enjoys playing water polo as well as being active with aerobics and running. ALLERGIES Patient reports history of seasonal allergies. MEDICATIONS Patient reports using an albuterol inhaler, 2 puffs as needed. REVIEW OF SYSTEMS Constitutional: Reports fatigue. Respiratory: Reports shortness of breath. Psychiatric: Reports mood changes. PHYSICAL EXAM Ears, Nose, Mouth, and Throat - Examination of Ears: Mild fluid in ears. - Examination of Mouth: Normal. - Examination of Throat: Tonsils have been previously removed. Gastrointestinal - Auscultation: Bowel sounds normal in all 4 quadrants. Integumentary - Examination: No rash or lesions. Normal capillary refill and perfusion. - Palpation: No enlarged lymph nodes. ASSESSMENT AND PLAN 1. Asthma. - Medical Reasoning: The patient has experienced an increased need to use her albuterol inhaler. She is not currently utilizing a daily medication. At this time, we will try a daily medication since it looks like she might be having some allergies. - Patient Education and Counseling: I explained the side effects of albuterol to the patient. We also discussed Singulair and that she should start to see a difference in her breathing within approximately 1 month. - Medical Treatment: We will start her on a daily asthma medication. She can continue to use the albuterol inhaler. We will start her on Singulair in about a month. 2. Mood. - Medical Reasoning: The patient reports being under a lot of stress with school. I believe this may be attributing to her mood. - Medical Treatment: I would like for the patient to be seen by a therapist. She will also complete our screening questionnaire. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 6 weeks for recheck.
ACI037
aci
[doctor] carolyn is a 34 -year-old female with a history of diabetes mellitus type two who is here today with a headache so hi there carolyn it's nice to see you again listen i'm sorry you're having headaches well let's talk about it but i would like to record this conversation with this app that's gon na help me focus on you more would that be okay with you [patient] yes that's okay [doctor] okay great thanks so carolyn tell me about your headache and headache or headaches when did when did they start and and what symptoms are you having [patient] my headache started about a week ago it's feeling like a dull pain in the back of my head i have flushing in my ears they get really red and hot and sometimes i just feel a little bit dizzy when i get these headaches but i've taken tylenol and advil and it's not really going away it just keeps coming back [doctor] okay and alright and so this started about a week ago has it been fairly constant since it started or does it come and go does it come and go or what [patient] it comes and goes it it's relieved when i take my tylenol or advil but then it comes right back [doctor] hmmm okay and do you notice any any timing difference you know is it is it worse in the morning worse in the evening is there anything else that makes it better or worse [patient] it's definitely worse in the evening [doctor] okay and do you feel any sort of tightness in the back of your neck or in your shoulders or you know you said it's in the back of your head primarily any discomfort anywhere else [patient] yes no just in the back of my head [doctor] okay and did the headache start all of a sudden carolyn or has it been gradual or what [patient] i've been under a lot of stress lately so maybe about when some stress started occurring [doctor] okay okay and alright and have you noticed any fever along with the headache [patient] no no fever [doctor] okay and any visual changes you know wavy lines in your vision spots in your vision or anything like that [patient] no [doctor] okay and have you had headaches like this before [patient] i have [doctor] okay so this is n't the worst headache you've ever had what did you say [patient] no it's not [doctor] okay alright and so okay fair enough now how's your diabetes been been been doing lately have you what have your blood sugars been running in the low one hundreds or two hundreds or what [patient] i have n't been checking my blood sugars [doctor] really okay well we will get you back on that and and we can talk about that but how about your metformin are you still taking the five hundred milligrams once a day no actually it looks like we increased your metformin to five hundred milligrams twice a day last visit are you still taking that [patient] yes [doctor] okay great and okay you're still watching your diet and getting some exercise [patient] i have not been eating well because i've been stressed over the last week but i have n't been exercising for maybe the past week but generally i've been doing better [doctor] okay the headache has has maybe made you feel uncomfortable and prevented your your exercise would you say or what [patient] yes it has [doctor] okay okay so you probably have n't been out golfing i remember you're a big golfer so not not lately uh so you know being [patient] not lately [doctor] being down being down here in florida we got ta get get some golf in so hey did you see the masters by the way a few weeks ago was n't that i do n't know did you happen to catch it [patient] i did [doctor] yeah that was crazy what a what a finish what an amazing what an amazing tournament right what do you think yeah yeah that's great well we'll we'll get you feeling better and get you back out there and now are you still working a lot on the computer ac or [patient] i am [doctor] carolyn okay yeah you're still working a lot on the computer for work okay are you taking breaks every hour or so you know get up stand around walk stand walk around that can be helpful [patient] no i really do n't get the opportunity to [doctor] hmmm okay understood alright well listen let's go ahead and examine you okay so so on your physical exam your physical exam is pretty normal unremarkable for the most part and you know few things a few exceptions so first of all on your heent exam your eye exam your extraocular motions are intact without pain you have a funduscopic exam that shows no papilledema that's good that just means there's no swelling in the back of your eye and on your neck exam you do have some posterior mild posterior paraspinal muscular tenderness in the cervical spine and in bilateral trapezius musculature as well and some tightness in those muscles as well and otherwise on your exam let's see your heart exam on your heart exam you have that grade three out of six systolic ejection murmur that's unchanged from your prior exam so it just means i hear some sounds in your heart as it's beating and i'm not too worried about that we'll watch that and otherwise normal heart exam and and your physical examination otherwise is normal and unremarkable and so now let's talk about my assessment and your plan so carolyn for your first problem of the headache i do think that you have a tension type headache and i think this because you've got some tension and tightness in your paraspinal muscles meaning the muscles around your neck and your shoulders and you know working at the computer i think is contributing to this and also probably the stress so you can continue to take that tylenol for the pain i'm also gon na give you a mild muscle relaxant i'll write you for flexeril five milligrams three times a day and you can take that that will help relax those muscles in your neck and that should help with the symptoms i want you to come back or give us a call if the headaches become more severe or suddenly worsen or you develop a fever but i do n't think that this is a a sign of a stroke or any bleeding in your brain or anything like that i think it's more related to tightness in your muscles in your neck now for your second problem of your diabetes mellitus let's continue you on the metformin five hundred milligrams i am going to order a hemoglobin a1c and also a cbc and a chem-12 to check some of your blood tests blood chemistries and so forth and we will continue you on the metformin i do want you to check your blood sugars daily and that will be very helpful so when you come back in a month i want you to bring those numbers with you we can talk about it again and please do try to get back into your exercise routine that's really gon na help you keep those blood sugars under control as well okay so how does that sound for a plan any other questions for me [patient] well would it so only call if if it gets worse or not any better [doctor] yeah that that just right but also let's set up an appointment in four weeks and i wan na see you back in four weeks if it's not if the headache is not better within the next few days with this flexeril then you can give us a call and and get back in later this week or early next but definitely if things get worse give us a call sooner and you know i meant to ask you on i wanted to ask if you had a history of any any trauma meaning have you hit your head or you have n't fallen hit your head or anything like that have you [patient] no no i think it's just stress [doctor] okay alright understood okay great well then i'll see you back in a month if not before okay you take care of yourself nice seeing you [patient] thank you [doctor] sure
CHIEF COMPLAINT Headache. MEDICAL HISTORY Patient reports history of diabetes mellitus type 2. SOCIAL HISTORY Patient reports she enjoys golfing. MEDICATIONS Patient reports taking metformin 500 mg twice a day. REVIEW OF SYSTEMS Constitutional: Denies fever. Eyes: Denies vision changes. HENT: Reports ear flushing. Neurological: Reports headaches and dizziness. PHYSICAL EXAM Eyes - Examination: No papilledema. - Extraocular Muscles: Grossly Intact without pain. Neck - General Examination: Mild posterior paraspinal muscular tenderness in the cervical spine and bilateral trapezius musculature as well tightness. Cardiovascular - Auscultation of Heart: Grade 3 out of 6 systolic ejection murmur that is unchanged from prior exam. ASSESSMENT AND PLAN 1. Headache. - Medical Reasoning: Patient presents with symptoms similar to a tension headache. On exam she has tension and tightness in her paraspinal muscles as well likely due to working at the computer. Additionally, I think her stress level is also a contributing factor. - Patient Education and Counseling: I discussed the diagnosis with the patient today. I explained that her headaches may be caused by tension around the muscles around her neck and shoulders. I advised her that her symptoms do not appear related to signs of a stroke or brain bleeding. Questions were asked and answered today. - Medical Treatment: She can continue to take Tylenol for the pain. Prescription for Flexeril 5 mg 3 times a day is provided as well. 2. Diabetes mellitus. - Medical Reasoning: Due to her headaches, she has been inconsistent with her exercise and checking her blood sugar. - Patient Education and Counseling: We discussed the importance of maintaining a healthy lifestyle. We also discussed the importance of keeping a watchful eye on her blood sugar levels. - Medical Treatment: She will continue taking metformin 500 mg daily. Order for hemoglobin A1c, CBC, and CMP provided today. She will check her blood sugar daily and will bring that information in on her next visit. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS The patient will follow up in 1 month. She can follow up or call sooner if her headaches become more severe or suddenly worsen or she develops a fever.
ACI038
aci
[doctor] hi virginia how're you today [patient] i'm good thanks how are you [doctor] good so you know you got that knee x-ray when you first came in but tell me a little bit about what happened [patient] i was playing basketball and jerry ran into me and the inside of my knee hurts [doctor] okay did you fall to the ground or did you just kinda plant and he pushed and you went one way and your knee did n't [patient] i did fall to the ground [doctor] you did fall to the ground okay and did you land on the kneecap i mean did it hurt a lot were you able to get up and continue on [patient] i landed on my side i was not able to continue on [doctor] okay so you get off the off the court is jerry a good player you just got ta ask that question [patient] not really [doctor] no [patient] he does n't have much game [doctor] okay okay well you know i love basketball i'm a little short for the game but i absolutely love to watch basketball so it's really cool that you're out there playing it so tell me about a little bit about where it hurts [patient] on the inside [doctor] on the inside of it okay and after the injury did they do anything special for you or you know did you get ice on it right away or try anything [patient] i had ice and an ace wrap [doctor] you had ice and what [patient] an ace wrap [doctor] and an ace wrap okay now how many days ago was this exactly [patient] seven [doctor] seven days ago okay yeah your right knee still looks a little swollen for seven days ago so i'm gon na go ahead and now i also see that you're diabetic and that you take five hundred milligrams of metformin twice a day are you still you're still on that medication is that correct [patient] correct [doctor] and do you check your blood sugars every morning at home [patient] every morning [doctor] okay great and since this i'm the reason i'm asking all these questions i'm a little concerned about the inactivity with your your knee pain and you know how diabetes you need to be very you know active and and taking your medicine to keep that under control so you know may wan na continue to follow up with your pcp for that diabetes as we go through here and just watch your blood sugars extra as we go through that now i'm gon na go ahead and examine your your right knee and when i push on the outside does that hurt at all [patient] no [doctor] okay and when i push on this inside where it's a little swollen does that hurt [patient] yes [doctor] yeah okay i'm just gon na ask a question did you hear or feel a pop in your knee when you were doing this [patient] i did not no [doctor] you did not okay okay what are you doing for the pain today [patient] some exercises ice and motrin [doctor] okay okay so i'm gon na continue all of my exam when i go ahead and pull on your knee the first thing i'm looking at is i do see some ecchymosis and swelling on the inside of that right knee and when i push around that knee i can see that there is fluid in the knee a little bit of fluid in the knee we call that effusion so i can appreciate some of that effusion and that could be either fluid or blood at this point from the injury that you had now you do have pain with palpation on the medial aspect of that right knee and that's that's concerning for me when i'm gon na just i just wan na move your knee a little bit it does n't look like when i extend it and flex it that you have a full range of motion does it hurt a lot when i moved it back a little more than normal [patient] yes it hurts [doctor] okay okay yeah so you do have some decreased range of motion in that right knee now i'm just gon na sit here and and lay you back and i'm gon na pull on your knee and twist your knee a little bit okay you currently there is a negative varus and valgus stress test that's really important so here's what i'm thinking for that right knee i think you have may have a medial collateral ligament strain from you know maybe the twisting motion be right before you fell to the ground i want you to continue to use an ace wrap i'm gon na give you a right knee brace we're gon na wear that for a few days and then i'm gon na send you to physical therapy so we can continue strengthening the muscles around the right knee now that x-ray as far as the x-ray results that x-ray that i did it this morning in the office the the bony alignment's in good position i do n't see any evidence of any fractures i do notice the the effusion around the right knee just a small amount of fluid but we're just gon na continue to watch that i'm gon na give you a prescription i'd like you to stop taking any of the nonsteroidals that you're taking the motrin or advil whichever one of those and i'm gon na give you meloxicam fifteen milligrams and i want you to take that daily for the pain and swelling i want you to just continue exercising with the the braces and everything on so if you can you can get out and do some light walking that'll be good and then again for your diabetes like i said just continue to watch those blood sugars daily and if you start to see any significant increase in them because of your loss of activity just reach out to your primary care physician now do you have any questions for me [patient] when can i play basketball again [doctor] yeah that's a great question i'm gon na ask well my first off i want to see you back here in in seven days you know in a week i want you to make an appointment we're gon na relook at it we're gon na determine if that swelling got any worse and if we need to go on to potentially ordering like a cat scan or an mri of that knee to look and see if there was any significant damage to the ligament so that's for for sure for seven days you're not gon na be playing basketball now are you in a ligue or is that just you get like pick up basketball [patient] i just pay at the y for fun [doctor] okay okay good that's a great activity like i said i wish i could play now i also know your your family do n't they own that sports store down right off a main street that sells a lot of sporting equipment [patient] yeah they do [doctor] okay i you know i'm i'm just thinking you know i need to get some new shoes for some of it my activities i love the i wish i could play basketball but i do a lot of bike riding so i'm always looking for anything that's gon na help me on the bike do you does your family have supplies like that [patient] we do let me know and i can get you the hook up [doctor] okay great great so i'll i will let you know i'll just get on and take a look first but i'm gon na go ahead and get get you discharged i'll have my assistant come in we will get you discharged and like i said we will make an appointment for seven days and we will go from there any questions [patient] i think you've answered them all thank you [doctor] okay great
CHIEF COMPLAINT Right knee pain. HISTORY OF PRESENT ILLNESS Virginia Phillips is a pleasant 53-year-old female who presents to the clinic today for the evaluation of right knee pain. The onset of her pain began 7 days ago, when she was playing basketball and another player ran into her. She states that she fell to the ground and landed on her side. She denies hearing or feeling a pop at the time of the injury. The patient localizes her pain to the medial aspect of her knee. She used ice and an ACE wrap right after the injury. Today, she notes that she has been doing exercises, ice, and Mobic for pain control. MEDICAL HISTORY The patient reports she is a diabetic who takes her blood sugar every morning. SOCIAL HISTORY Patient reports that she plays basketball at the Y for fun. MEDICATIONS Patient reports that she takes metformin 500 mg twice a day. REVIEW OF SYSTEMS Musculoskeletal: Reports right knee pain. PHYSICAL EXAM MSK: Examination of the right knee: No pain to palpation of the lateral aspect of the right knee. Pain with palpation on the medial aspect of the knee. Ecchymosis and swelling on the medial aspect of the knee. Effusion is appreciated. Decreased ROM. Negative varus and valgus stress test. RESULTS X-rays of the right knee taken in office today reveal the bony alignment in good position. There is no evidence of any fractures. There is effusion present. ASSESSMENT Right knee pain, possible medial collateral ligament strain. PLAN After reviewing the patient's examination and radiographic findings today, I have had a lengthy discussion with the patient in regard to her current symptoms. I have prescribed the patient meloxicam 15 mg once a day to treat the pain and swelling. She was advised to stop taking any anti-inflammatory such as Motrin or Advil. I have also recommended that the patient attend formal physical therapy to strengthen her right knee. I have also advised her to continue to use the ACE wrap and wear a right knee brace for a few days. She should continue light walking with her brace on. The patient was advised to stop basketball until she follows up in 7 days. Regarding her diabetes, she should continue to monitor her blood sugars daily. She should reach out to her primary care physician if she sees an increase in her blood sugars due to loss of activity. INSTRUCTIONS The patient will follow up with me in 7 days to check on her progress. If her swelling has not improved, we will consider obtaining a CT or MRI of the right knee to evaluate for a possible medial collateral ligament strain.
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[patient] hey bruce so see here my my notes here is you here he had positive lab work for hep c so how're you doing today [doctor] i'm doing okay but i'm a little bit anxious about having hep c i've really surprised because i've been feeling fine they had done it as you know a screen as just part of my physical so i'm really surprised that that came back positive [patient] okay so in the past have any doctors ever told you that you had hep c [doctor] no never that's why i'm i'm so surprised [patient] okay so just you know i need to ask do you have a history of iv drug use or you know have known any hep c partners [doctor] i mean i used to party a lot and even did use iv drugs but i have been clean for over fifteen years now [patient] okay that that's good i mean i'm i'm happy that you were able to to kick that habit i know a lot of my patients that i see you know they're still dealing with with those dements so i'm i'm i'm happy that you're able to do that so hopefully we can get you better okay [doctor] thank you [patient] so what about alcohol use is that something that you used to do a lot [doctor] i did i did i mean i still have a beer here and there everyday but not as much as i used to [patient] okay and have you ever smoked before [doctor] i do smoke i smoke about one to two cigarettes per day i've cut down a lot but i'm just having a hard time kicking those less too [patient] yeah yeah and that that's something i've got to work on too because hep c along with smoking you know both of those are n't are n't good so hopefully we can help you out you know if your pcp has n't prescribe something for you already and possibly we can we can do that for you as well [doctor] okay [patient] so do you have any other medical conditions [doctor] no i'm actually other than that i just had my physical and i'm not taking any medications no i'm i'm pretty good otherwise [patient] okay and what conditions would you say run in your family [doctor] i have high blood pressure diabetes and depression [patient] okay [doctor] alright so let me go ahead and do a quick physical exam on you so i reviewed your vitals and everything looks good and on general appearance you appear to be in no distress no jaundice on the skin on your heart exam you have a nice regular rhythm rate [patient] regular rate and rhythm with a grade two out of six systolic ejection murmur is appreciated on your lung exam your lungs are clear without wheezes rales or rhonchi on your abdominal exam bowel sounds are present your abdomen is soft with no hepatosplenomegaly [doctor] hepatosplenomegaly yes let me i will change that one [patient] splenomegaly and on your muscle exam there is no gait disturbance or edema so i did we i was able to review your your results of your recent lab work and your hcv antibody test was positive so your your liver panel we did one of those and it showed an elevated ast at thirty nine but your alt albumin and total bilirubin were all within normal limits so that's pretty good so let's talk a little bit about my assessment and plan for you so you do have hepatitis c so your initial labs were consistent with that hep c diagnosis and so you know i do n't know if you read much about hep c but hepatitis c is a viral infection that does affect your liver and you've most likely had it for several years now it it it most patients do n't see symptoms until years later so the next step that i would like to do is just confirm the diagnosis with some additional blood work so that includes checking your hep c rna and your hcv genotype and i would also like to determine the severity of your liver disease by checking for fibrosis of the liver and we will do that by ordering an ultrasound elasto elastography with this information we will we we will be able to know how we can proceed as far as treatment right so how does that sound [doctor] i hmmm so i do have a wife and kids so should i be worried about them [patient] okay yeah so we can start with the same screening that you had for august first so we'll just let's do that hep c antibody test and i'll actually help you set up those appointments with your your family doctor and then we can just see you back in three weeks and based on the results you know we will take action as needed okay [doctor] okay that sounds good [patient] alright [doctor] alright [patient] my nurse will be in with those those orders [doctor] alright thank you [patient] alright thanks [doctor] bye
CHIEF COMPLAINT Hepatitis C. HISTORY OF PRESENT ILLNESS Bruce Ward is a pleasant 60-year-old male who presents to the clinic today following a positive result in a hepatitis C antibody test. He was sent to obtain the hepatitis C antibody test as part of a routine physical. He states he is anxious with the results and denies he has ever been diagnosed with hepatitis C. The patient admits to intravenous drug use in the past; however, he notes it has been longer than 15 years since his last usage. He also reports a history of heavy alcohol use. He continues to drink a beer on occasion. The patient currently smokes 1 to 2 cigarettes per day. He notes he used to smoke more and is having difficulty with complete cessation. MEDICAL HISTORY The patient denies any significant past medical history. SOCIAL HISTORY The patient is married with children. He reports history of IV drug use 15 years ago. He currently drinks beer occasionally. The patient reports smoking 1 to 2 cigarettes per day. FAMILY HISTORY He reports a family history of high blood pressure, diabetes, and depression. MEDICATIONS Patient denies taking any current medications. VITALS All vital signs are within normal limits. PHYSICAL EXAM CONSTITUTIONAL: In no apparent distress. CV: Regular rate and rhythm. Grade 2 out of 6 systolic ejection murmur is appreciated. RESPIRATORY: Lungs are clear without wheezes, rales, or rhonchi. GI/GU: Abdomen is soft with no hepatosplenomegaly. Bowel sounds are present. SKIN: No jaundice. RESULTS The HCV antibody test was reviewed today and is positive. Liver panel revealed an elevated AST at 39 U/L. The ALT, albumin, and total bilirubin were all within normal limits. ASSESSMENT Hepatitis C. PLAN After reviewing the patient's laboratory findings today, I have had a lengthy discussion with him in regard to his current symptoms. His initial labs were consistent with a hepatitis C diagnosis. I have recommended that we confirm the diagnosis with additional blood work including checking his hepatitis C RNA and HCV genotype. I have also recommended that we obtain an ultrasound elastography to evaluate for fibrosis of the liver. The patient is married with children and is concerned about their hepatitis C status. I advised the patient that his family should be screened and we will assist him with setting appointments with their primary care physician. INSTRUCTIONS The patient will follow up with me in 3 weeks to review his results and discuss further treatment.
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[doctor] alright [patient] you're ready just [doctor] ready [patient] hi kyle how are you today [doctor] i'm doing well i'm just anxious about my pcp told me that i had some abnormal lab work and why she wanted me to be seen by you today [patient] yeah i bet that did make you nervous i see that she referred you for a low immunoglobulin a level is that your understanding [doctor] yeah i mean i do n't even really understand what that means but yeah that's what she told me [patient] yeah that's a mouthful [doctor] yeah [patient] it it's the the one of the antibodies in your body and that that really makes that your body makes to fight infections it's a little bit low i'm happy to explain it a little bit more to you i just have a few more questions okay so let's start again here [doctor] i'll do this [patient] i think i would break that [doctor] yeah i just saw that [patient] if you can do that [doctor] okay [patient] yeah so we'll we'll just [doctor] okay [patient] you can leave it the way it is for now i just i think break that up [doctor] okay alright so yeah that sounds fine for me [patient] yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections [doctor] yeah yeah i had a recent physical and she did this as part of her my physical i do tend to get infections but i do n't know i'm so used to it so i do n't know if this is more than usual in the wintertime i get a lot of colds and they do seem to i always say that my colds kind of linger for a long time but i do n't know if it's more than usual [patient] okay how about any abdominal infections [doctor] diarrhea no [patient] frequently [doctor] no not that i can not that i say can think of [patient] okay what about your family are are anyone in your family that you know have immune deficiencies [doctor] no my family is actually pretty healthy [patient] okay and how about do you have any other medical conditions [doctor] yeah my pcp just started me on metformin i just got diagnosed with type two diabetes [patient] okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street [doctor] yes and that's probably part of the cause of my diabetes yes [patient] yeah well i guess you're gon na have to watch that [doctor] i know i know [patient] but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away [doctor] right [patient] but have you ever needed to receive a blood transfusion or blood products [doctor] no i actually tried to give blood but they i did n't qualify because i had recently traveled internationally [patient] okay where did you go [doctor] i was in zambia [patient] hmmm i heard that's beautiful [doctor] it's so beautiful it's so beautiful i had a great time [patient] okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial [doctor] no [patient] no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about the assessment and plan so for your first problem the that a iga deficiency is it very common immunodeficiency your your body makes many different types of antibodies in one of your z iga is just a little bit lower than normal now most of the time people live their entire life without even knowing they have that deficiency and function perfectly normal now some people may find that they get tend to get frequent respiratory tract or sinus or abdominal infections but this does n't necessarily seem to be the case for you now it can go along with other immunodeficiencies but i think there is a low likelihood hood in your case but we're gon na order some additional blood work that includes checking those other antibodies now do you have any questions on what i just told you [doctor] yeah so is there anything i need to do or should be watching for or should i be worried [patient] no i really do n't think you need to be worried now we're gon na check these additional studies and that will give us some more guidance but really i think this is just a finding that's common to you and you know it it's many people have have have these type of you know immunodeficiency what i want you to watch for is those infections that do n't stop you have trouble getting it under control or you know any changes to your abdominal tract you know severe diarrhea [doctor] anything like that then you know we may want to look at it a little bit further but for now i do n't think there is anything significant we want to do now go ahead and get your lab work and [patient] bring you in for that now the only other thing that i would say is if you eat end up needing any blood products between now and when i see you next make sure you tell them that you have that iga deficiency [doctor] why is that [patient] well there is a risk that your body can strongly react to some blood products and they just need to know that so they're prepared so anytime you get blood just make sure you say that you have a history of a an an iga deficiency [doctor] okay okay thank you [patient] you're welcome [doctor] okay
HISTORY OF PRESENT ILLNESS Kyle Lee is a pleasant 46-year-old male who presents to the clinic today for evaluation of low immunoglobulin A level. He was referred to our offices by his primary care physician after routine labs revealed abnormalities. The patient states he has been experiencing frequent infections. During the winter months, he experiences frequent colds that tend to linger, however this is not uncommon for him. The patient denies abdominal issues or diarrhea. The patient was recently diagnosed with type 2 diabetes. He is currently taking metformin. MEDICAL HISTORY Patient denies a history of blood transfusions. SOCIAL HISTORY He recently traveled internationally on a trip to Zambia. His family owns a local doughnut shop. FAMILY HISTORY Patient denies a family history of immune deficiencies. REVIEW OF SYSTEMS Gastrointestinal: Denies abdominal issues or diarrhea. VITALS Temperature: Normal. All other vitals were reviewed and are within normal limits. PHYSICAL EXAM NECK: No swelling noted. No lymphadenopathy. CV: Normal heart rhythm with no murmurs. RESPIRATORY: Lungs are clear. There's no wheezes, rales, or rhonchi. Gastrointestinal: Abdomen is soft and without tenderness. RESULTS I did review the results of her recent lab work. It is consistent as her primary care physician noted with an IgA deficiency. ASSESSMENT IgA deficiency. PLAN After reviewing the patient's examination today, I have had a lengthy discussion with the patient in regards to his current symptoms. I have explained to him that the results of his recent lab work is consistent with an IgA deficiency. I have recommended that we obtain additional blood work to check his other antibodies. I encouraged the patient to be aware of lingering infections or abdominal changes including diarrhea. If he experiences these issues, he should report them to my office so we may investigate further, however I do not believe there is a need for that at this time. In the meantime, he should report this IgA deficiency in the event that he needs any blood transfusions. Questions were invited and answered today.
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[doctor] how are you doing [patient] i'm doing i'm good i'm i'm doing really good i'm here i'm just ready to quit smoking and but i've been having quite a hard time with it [doctor] well i'm glad that you're taking the first steps to quit smoking would you tell me a little bit more about your history of smoking [patient] yeah so i've been smoking for some time now i started in high school and was just you know just experimenting and smoking here and there with friends or at parties and then it just started getting more regular and regular and i do n't even know how i'm 44 now and i'm smoking everyday so yes now i'm up to a pack and a half a day [doctor] okay do you use any other type of tobacco products [patient] no smoking is enough [doctor] okay and i understand that so when you wake up in the morning how soon after waking up do you smoke your first cigarette [patient] i would say probably within an hour of waking up i'll have my first cigarette [doctor] okay so i'm really excited that you wan na quit and i know that you probably heard this multiple times before but this really is one of the best things that you can do to help your health especially since you have the history of gout and type two diabetes this is really gon na be a great step in you having better long term health outcomes [patient] yeah i know and you know i'm really motivated now because i am about to be a father any day now and i just really wan na be there for my daughter growing up [doctor] hey that's great and that's great to hear congratulations i'm so excited to hear about the new baby [patient] yeah [doctor] i have a daughter myself have have you picked out any names [patient] we're you know we're deciding between a few names but we're kinda just waiting to see her to see which name fits [doctor] okay alright that sounds good well congratulations again i'm very excited for you and your and and your wife that that's this is great [patient] thank you [doctor] so you mentioned you tried to quit before can you tell me a little bit about the methods that you used or or what you tried [patient] yeah actually i just went cold turkey one day i woke up and i said you know i've had enough and i know that smoking is not good for me so i woke up and stopped and i actually did really well and i was able to quit smoking for almost a year and then things just started getting really stressful at work they started laying people off and i'm happy i still have a job but that also meant that i was responsible for more things so things just got stressful and i and just started picking it up again [doctor] well you are absolutely correct you know stress can often be a trigger for things like smoking and drinking have you thought what you would do this time when you encountered the stressful situations [patient] yeah i did n't think about that a lot actually and one thing is i have started learning and trying to do more meditation and then i also just recently joined the gym so i'm really looking forward to working out again [doctor] okay well that's great to hear that you're getting back in the gym that will be good for your long term health too you know helping to maintain that type two diabetes you know those are really great strategies talking about gym for stress relief and and you know we have other products as well that you can use for an additional aid to help you stop smoking have you given any thought to using some type of smoking cessation aid at this time or or what do you think about that [patient] you know i've had you know because i've been trying to do cold turkey and it's not working and some of my friends actually have mentioned using a patch and they they've had some success with that so i think i would i would probably wan na start with that [doctor] okay alright that that sounds good it's good that you've you've picked out one of those aids and have you thought of a quit date i mean we we really wan na talk about when you're gon na say this is the day [patient] yeah you know next monday is actually my birthday so i think that's a good day [doctor] that's a fantastic day and happy birthday coming up on monday [patient] thank you [doctor] so let's talk a little bit about your exam here okay i'm gon na go ahead and do a quick physical exam and i reviewed your vitals and everything looks good including your oxygen saturation blood pressure for today was one twenty eight over eighty eight heart rate was sixty eight respirations were sixteen and your pulse ox was ninety eight percent on room air so those were all really good now on your heart exam you do have a nice regular and your your rate is of regular rate and rhythm or i'm sorry your heart exam for your heart exam notice that your heart is regular in rate and rhythm i do however still appreciate that two over six systolic murmur that we talked about in the past now that's okay we'll just continue to monitor that now for your lung exam i'm gon na go ahead and listen to your lungs your lungs are clear and equal bilateral with no expiratory wheezes and no rales or rhonchi are appreciated on your neck exam i do n't appreciate any lymphadenopathy when i listen i do n't hear any extra noises so i do n't hear any hearing any carotid bruit which is a good thing now for my impression and plan let's talk a little bit about my assessment and plan for you so for your first problem of nicotine dependence first of all i just want to apply you on making this first step to stop smoking and i want you to know with absolute one hundred percent certainty that i'm gon na be with you every step of the way i think it's fantastic that you're very welcome i think it's fantastic you've chosen next monday as a quit date and on that day i'm gon na start you with a twenty one milligram nicotine patch and the goal will be to decrease that over time okay now we will work together to decrease that so there is no necessarily hard dates in mind okay be sure to change the patch location each day and that's going to help reduce or avoid that skin irritation that can occur if you use the same location over and over again i would like to see you again in two weeks just to see how things are going and we will reevaluate at that time the dosage for your nicotine patch now we also see further need to discuss any handouts you received today for those common smoking triggers i really want you to keep an eye on and monitor your stress level not only about work but also the fact that you are experiencing are going to be be a new father and we really want to watch any stress you will be experiencing around the birth of your new child so please keep an eye on that and let me know how that goes now for now until we meet in two weeks go ahead and keep up your exercise routine i think that's a great plan and just try to monitor your stress and and maybe think about some things like meditation or adding in some yoga and that type of thing to help further work with your your stress levels so do you have any questions for me [patient] no not at this time [doctor] okay so for your other conditions that we talked about briefly your second condition of type two diabetes we'll let's go ahead and continue to maintain that with diet and exercise and we'll just monitor your type two diabetes i am gon na go ahead and order a hemoglobin a1c for your next blood draw since i'll see you in two weeks go ahead and have that done and we will talk about that when you come back in now for your third problem of your history of gout let's go ahead and continue you on your allopurinol and just you know continue to watch those foods that will exacerbate your uric acid levels any other questions about those [patient] no i think that's it thanks so much [doctor] alright sounds good i'll see you in two weeks congratulations on the baby and and we're excited about next monday that's your quit date [patient] alrighty thank you [doctor] you're welcome i'll see you in two weeks thanks bye-bye [patient] alright bye
CHIEF COMPLAINT Smoking cessation. MEDICAL HISTORY Patient reports a history of type 2 diabetes, gout, and a 2/6 Systolic ejection murmur. SOCIAL HISTORY Patient reports he is a smoker. MEDICATIONS Patient reports taking allopurinol. VITALS Oxygen Saturation: 98% on room air. Blood Pressure: 128/88 mmHg. Heart Rate: 68 beats per minute. Respiratory Rate: 16 breaths per minute. PHYSICAL EXAM Neck - General Examination: Neck is supple without lymphadenopathy. No carotid bruits. Respiratory - Auscultation of Lungs: Clear bilaterally. No expiratory wheezes, rales, or rhonchi. Cardiovascular - Auscultation of Heart: Regular rate. 2/6 systolic ejection murmur. Hematology/Lymphatic/Immunology - Palpation: No enlarged lymph nodes. ASSESSMENT AND PLAN 1. Nicotine dependence. - Medical Reasoning: The patient has a long history of smoking cigarettes. He is currently smoking 1.5 packs per day. He is highly motivated to cease smoking as he is preparing to become a father. - Patient Education and Counseling: I applaud the patient on making this first step to stop smoking. I reassured him that with absolute 100% certainty that I will be with him every step of the way. I explained to the patient that stress can often be a trigger for smoking. He received handouts today for common smoking triggers. I advised him to be watchful and monitor his stress level, not only regarding work, but also his impending fatherhood. The patient and I discussed coping mechanisms for when he encounters stressful situations. I encouraged him to maintain his gym routine, engage in meditation, and try adding in yoga to help further reduce his stress levels. We discussed additional cessation aids. - Medical Treatment: The patient has chosen his birthday, as a quit date. On that day, I am going to start him with a 21 mg nicotine patch, and the goal will be to decrease that over time. We will work together to decrease the dosage of the nicotine patch, so there are not necessarily any hard dates in mind. I recommend he change the patch location each day as that will help reduce or avoid any skin irritation that can occur if he re-uses the same location repeatedly. 2. Type 2 diabetes. - Medical Reasoning: Stable. - Patient Education and Counseling: We discussed that continuing to follow a healthy diet and perform regular exercise will help to maintain his blood glucose levels. - Medical Treatment: We will continue to monitor his type 2 diabetes. Hemoglobin A1c is ordered to be completed by his next visit in 2 weeks. 3. History of gout. - Medical Reasoning: Stable with medication. - Patient Education and Counseling: I advised him to continue to watch for foods that will exacerbate his uric acid levels. - Medical Treatment: He will continue his allopurinol. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan. INSTRUCTIONS I would like to see him again in 2 weeks to discuss how things are going and to reevaluate the nicotine patch dosage.
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[doctor] hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on [patient] and i've been in a lot of pain it started about i would say probably about three days ago [doctor] okay [patient] started having pain on my left back [doctor] okay [patient] and since then i continued to have pain it is traveling a little lower it's gotten little low but i definitely have not passed it yet and i'm just in so much pain [doctor] okay so is the pain that you're having is it constant or does it come and go [patient] it's constant [doctor] okay [patient] all the time i ca n't get comfortable [doctor] alright are you able to urinate [patient] i am and this morning i actually started seeing some blood [doctor] okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes [patient] i've had it for probably this might be my third time [doctor] third time alright [patient] yeah i have n't had one in a while but yeah this is my third time [doctor] okay so have you noticed any nausea chills fever [patient] no fever some chills and i just in so much pain i ca n't eat and i do feel a little nauseous [doctor] okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain [patient] yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working [doctor] okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved [patient] yeah usually usually about about three four days to pass it yeah [doctor] right so this is this is the looks like this is the third day [patient] yeah [doctor] so we are getting close there [patient] okay [doctor] yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff [patient] i was i have n't been great about taking it but i did get the blood pressure cuff [doctor] so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running [patient] like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty [doctor] okay [patient] and then the bottom number has been between seventy and eighty okay that i mean that's not too bad i think when you were first diagnosed you were up there in the [doctor] the one eighties which was really high [patient] right [doctor] so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that [patient] trying my best but doc i really like my french fries [doctor] yeah [patient] like [doctor] we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help [patient] yeah some help could be helpful okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright [doctor] so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday [patient] i have and those those have been pretty good they are like in the low one hundreds [doctor] okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday [patient] i do [doctor] okay [patient] i do take it [doctor] that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain [patient] no chest pain [doctor] no chest pain are you having any belly pain [patient] the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain [doctor] no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt [patient] yes [doctor] okay i'm gon na press here on your back is that painful [patient] yes [doctor] alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tenderness on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound [patient] that sounds good and i just i just want this pain to go away so thank you [doctor] okay no problem
CHIEF COMPLAINT Left-sided back pain. MEDICAL HISTORY Patient reports history of history of hypertension, diabetes, and kidney stones. MEDICATIONS Patient reports taking Tylenol, occasional ibuprofen, Norvasc 2.5 mg daily, and metformin 500 mg daily. REVIEW OF SYSTEMS Constitutional: Reports chills and decreased appetite. Denies fever. Cardiovascular: Denies chest pain. Gastrointestinal: Reports nausea. Denies abdominal pain. Genitourinary: Reports hematuria. Musculoskeletal: Reports left-sided back pain. VITALS Blood pressure is slightly elevated, likely due to patient's pain level. PHYSICAL EXAM Respiratory - Auscultation of Lungs: Clear bilaterally. No wheezes, rales, or rhonchi. Cardiovascular - Auscultation of Heart: Grade 2 out of 6 systolic ejection murmur, unchanged. Gastrointestinal - Examination of Abdomen: Tenderness to palpation of the abdomen. No rebound or guarding. CVA tenderness present at right flank. RESULTS Previous hemoglobin A1c is reviewed at 7.3. ASSESSMENT AND PLAN 1. Kidney stone. - Medical Reasoning: Patient presents today with symptoms consistent with kidney stones. She does have a history of kidney stones with this being her third episode. - Patient Education and Counseling: We discussed the importance of pushing fluids to help facilitate passing the kidney stone. - Medical Treatment: Prescription for oxycodone 5 mg every 6 to 8 hours as needed for pain was provided today. Tylenol is recommended for breakthrough pain. She will push fluids and has been provided with a urine strainer. Referral to urology was also provided due to her recurrent episodes. 2. Hypertension. - Medical Reasoning: Patient is currently stable and has not had any elevated readings. Her blood pressure was slightly elevated today, however, this is due to her current pain level. - Patient Education and Counseling: We discussed the importance of home blood pressure monitoring with the goal of at least 3 times per week. She was also advised on the importance of diet modification with limiting salt to 2300 mg daily. - Medical Treatment: Continue Norvasc 2.5 mg. Continue with home blood pressure monitoring 3 times per week. Limit salt intake to 2300 mg daily. 3. Diabetes. - Medical Reasoning: Patient is currently stable and has not had any elevated glucose readings. - Patient Education and Counseling: We discussed the importance of diet modification. - Medical treatment: Continue metformin 500 mg daily. Continue with home glucose monitoring before meals. Referral to a dietitian was provided. Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
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[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 was thinking that 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 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] 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
CHIEF COMPLAINT Left shoulder pain. HISTORY OF PRESENT ILLNESS Alan Mitchell is a pleasant 69-year-old male who presents to the clinic today for the evaluation of left shoulder pain. The onset of his pain began 3 weeks ago, without any improvement. He denies any specific injury; however, he has been renovating his basement and putting in a new ceiling. He does not recall hitting or falling onto the left shoulder. The patient states he is very active and has experienced left shoulder pain before that usually resolves with Tylenol. The patient reports significant pain with reaching, lifting, and overhead activities. The pain is constant. He states the pain is primarily located in the left shoulder and denies it radiates down into the left arm. The patient also reports difficulty sleeping secondary to the pain. He denies any numbness or tingling in his left arm or fingers. He has been taking Tylenol for pain, which provides partial relief. He initially iced his shoulder but has not iced it recently. The patient denies he has done any physical therapy. REVIEW OF SYSTEMS Musculoskeletal: Reports left shoulder pain. Neurological: Denies numbness or tingling. VITALS All vital signs are within the normal limits. PHYSICAL EXAM MSK: Examination of the left shoulder: Limited active and passive ROM. Tenderness over the greater tuberosity of the humerus. No tenderness at the sternoclavicular or AC joints. Good hand grip. Neurovascularly intact distally. Capillary refill is less than 3 seconds. Sensation is intact to light touch distally. RESULTS X-rays of the left shoulder were obtained and reviewed today. These are normal and reveal no fracture or bony abnormalities. 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. INSTRUCTIONS The patient will follow up with me once the MRI results are available for review and further discussion.

Overview

The MEDIQA-CHAT-2023 Benchmark contains a dataset structured for analyzing conversations between healthcare providers (e.g., doctors) and patients, as well as for clinical note generation tasks. It appears to focus on multi-turn dialogues that mirror real-world medical scenarios and corresponding structured clinical notes.

Structure

The dataset includes two primary fields:

  • dialogue (string):
    Multi-turn transcriptions of conversations between doctors and patients.

    • Conversations are marked with speaker roles such as [doctor] and [patient].
    • Example:
      [doctor] hey george how are you today i understand you're here for some numbness...
  • clinical_note (string):
    Structured medical notes extracted or generated from the dialogue.

    • Example:
      CHIEF COMPLAINT Left wrist and hand pain. HISTORY OF PRESENT ILLNESS George Lewis is...

Expanded Use Cases

The MEDIQA-CHAT-2023 Benchmark supports a range of applications in medical NLP, speech processing, and AI evaluation:

  1. Dialogue Understanding:

    • Extracting medical entities, symptoms, and details from clinician-patient conversations.
  2. Clinical Note Generation:

    • Automatically generating structured medical notes from multi-turn dialogues, reducing clinician documentation workload.
  3. Voice Actor Roleplay:

    • Simulating doctor-patient conversations with voice actors or synthetic voice models.
    • Use case: Creating realistic audio datasets for testing spoken conversational systems.
  4. Voice Synthesis (TTS):

    • Generating synthetic speech for dialogues using Text-to-Speech (TTS) systems.
    • Evaluating models' ability to replicate realistic doctor-patient exchanges.
  5. Automatic Speech Recognition (ASR) Evaluation:

    • Using roleplay or synthetic voices to generate audio inputs.
    • Benchmarking ASR systems for transcription accuracy on medical conversations.
  6. Benchmarking EHR Note Understanding:

    • Evaluating models' ability to process, understand, and extract information from Electronic Health Record (EHR) notes.
    • Use case: Developing AI systems to map doctor-patient dialogues to standardized EHR formats for better documentation and clinical decision support.
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