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[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 i 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

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.

[doctor] hi ms. hernandez , dr. fisher , how are you ? [patient] hi dr. fisher . i'm doing okay except for my elbow here . [doctor] all right . so it's your right elbow ? [patient] it's my right elbow , yes . [doctor] okay . hey dragon , ms. hernandez is a 48-year-old female here for a right elbow . so , tell me what happened . [patient] well , i was , um , moving to a new home- [doctor] okay . [patient] and i was , um , moving boxes from the truck into the house and i lifted a box up and then i felt like this popping- [doctor] hmm . [patient] and this strain as i was lifting it up onto the shelf . [doctor] okay . and when- when did this happen ? [patient] this was just yesterday . [doctor] all right . and have you tried anything for it ? i mean ... [patient] i put ice on it . and i've been taking ibuprofen , but it still hurts at lot . [doctor] okay , what makes it better or worse ? [patient] the ice , when i have it on , is better . [doctor] okay . [patient] but , um , as soon as , you know , i take it off then it starts throbbing and hurting again . [doctor] all right . uh , let's review your past medical history . uh ... looks like you've got a history of anaphylaxis , is that correct ? [patient] yes . yes , i do . yeah . [doctor] do you take any medications for it ? [patient] um , ep- ... just an epipen . [doctor] just epipen for anaphylaxis when you need it . um , and what surgeries have you had before ? [patient] yeah , so carotid . yeah- [doctor] . yeah , no , uh , your , uh , neck surgery . all right . well let's , uh , examine you here for a second . so it's your , uh , this elbow right here ? [patient] yeah . [doctor] and is it hurt- ... tender right around that area ? [patient] yes , it is . [doctor] okay . can you flex it or can you bend it ? [patient] it hurts when i do that , yeah . [doctor] all right . and go ahead and straighten out as much as you can . [patient] that's about it . [doctor] all right . [patient] yeah . [doctor] so there's some swelling there . and how about , uh , can you move your fingers okay ? does that hurt ? [patient] no , that's fine . [doctor] how about right over here ? [patient] uh , no that's fine . yeah . [doctor] okay . so on exam you've got some tenderness over your lateral epicondyle . uh , you have some swelling there and some redness . uh , you have some pain with flexion , extension of your elbow as well . uh , and you have some pain on the dorsal aspect of your- of your forearm as well . okay ? so let's look at your x-rays . hey dragon , show me the x-rays . all right . your x-ray of your elbow- it looks like , i mean , the bones are lined up properly . there's no fracture- [doctor] . it , uh , there's a little bit of swelling there on the lateral elbow but i do n't see any fracture , so that's good . so , looking at the x-ray and looking at your exam , uh , my diagnosis here would be lateral epicondylitis , and this is basically inflammation of this area where this tendon in- inserts . and probably that happened when you were moving those boxes . so we'll try some motrin , uh , about 800 milligrams every six hours . uh , i'll give you a sling for comfort , just so you can use it if- if it's causing a lot of pain . [patient] hmm . [doctor] and it should get better , uh , in about , you know , in a couple of days it should be improved . and if it does n't get better , give us a call and we'll see you some time next week . okay ? so we'll give you a sling , we'll give you the motrin , i'll give you about , uh , 30 , uh , uh , 30 , uh , uh , medications for that . uh , do you have any questions ? [patient] no , no . thank you . [doctor] hey dragon , order the medications and the procedures . all right , why do n't you come with me and we'll get you signed out ? [patient] okay , sounds good . [doctor] hey dragon , finalize the report .

PLAN At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a sling for comfort. We discussed ice and anti-inflammatory medications. I will prescribe Motrin, 800 mg to take every 6 hours. She will follow up with me as needed if she continues to have pain. All questions were answered. "

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

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.

[doctor] hi jerry , how are you doing ? [patient] hi , good to see you . [doctor] good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you . [patient] sure . [doctor] jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sclerosis who presents for an annual exam . so jerry , what's been going on since the last time i saw you ? [patient] uh , we have been traveling all over the country . it's been kind of a stressful summer . kinda adjusting to everything in the fall and so far it's been good , but ah , lack of sleep , it's been really getting to me . [doctor] okay . all right . and have you taken anything for the insomnia . have you tried any strategies for it . [patient] i've tried everything from melatonin to meditation to , uh , t- stretching out every morning when i get up . nothing really seems to help though . [doctor] okay . all right . [doctor] in terms of your osteoporosis , i know we have you on fosamax , any issues with your joints , any issues like- [patient] no . [doctor] no broken bones recently ? [patient] no . [doctor] no , nothing like that ? [patient] no . [doctor] okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ? [patient] uh , about six months ago . [doctor] okay and you're taking the medication ? [patient] yes . [doctor] okay . and any issues with that ? [patient] none whatsoever . [doctor] and any additional weakness ? i know you were having some issues with your right leg , but that seems to have improved or ? [patient] yes a lingering issue with my knee surgery . but other than that it's been fine . [doctor] okay . [patient] pretty , pretty strong , n- nothing , nothing out of the ordinary . [doctor] okay . all right , well i know you did a review of systems sheet when you checked in . [patient] mm-hmm . [doctor] and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ? [patient] no . [doctor] all right . well lets go ahead and do a quick physical exam . [patient] mm-hmm . [doctor] hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find . [patient] sure . [doctor] okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee . [patient] mm-hmm . [doctor] um , so let's go over some of your results , okay ? [patient] sure . [doctor] hey dragon , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . do you need a refill on that ? [patient] actually i do . [doctor] hey dragon , order a refill of fosamax 1 tab per week , 11 refills . and then in t- , for your second problem , your multiple sclerosis i want you to go ahead and continue to see the neurologist and continue on those medications . and let me know if you need anything from that standpoint , okay ? [patient] you got it . [doctor] any questions ? [patient] not at this point , no . [doctor] okay , great . hey dragon , finalize the note .

ASSESSMENT Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam. PLAN Osteoporosis. • Medical Reasoning: The patient is doing well with Fosamax. • Medical Treatment: Continue Fosamax 1 tab per week. Eleven refills were ordered today. Multiple Sclerosis. • Medical Reasoning: The patient is experiencing weakness of the bilateral lower extremities. He has been seeing his neurologist on a consistent basis and has been compliant with medication. • Medical Treatment: He will continue to follow up with his neurologist and comply with his medication regimen. Right knee arthritis. • Medical Reasoning: The patient recently underwent knee surgery. A recent right knee x-ray demonstrated some arthritic changes.