[doctor] hi , carolyn . how are you ?
[patient] good . how are you ?
[doctor] i'm good . you're ready to get started ?
[patient] yes , i am .
[doctor] so carolyn is a 49-year-old female here for follow-up of her chronic problems . so , how are you doing , carolyn ?
[patient] i'm doing okay . um , my osteoarthritis has been flaring up a little bit lately , um , so i wan na get- talk about that primarily . so , it's mostly in um , my elbows and it's really been bothering me . i've been sitting at the computer , at the desk more , um , in the office so i do n't know if it's being stagnant in that position all day has um , increased flare-ups for that , but i wanted to talk to you about that .
[doctor] okay , sure . and , are you right or left-handed ?
[patient] i'm right-handed .
[doctor] okay , and does one elbow bother you more than the other ?
[patient] my right elbow does bother me more than the other , but primarily , i'm typing all day versus writing , so it- it flares up in both .
[doctor] okay . all right , and um , any other joint pain ?
[patient] no , just- just really focused on my elbows .
[doctor] okay , and any numbing or tingling in your hands ?
[patient] uh , sometimes . when i'm typing for long periods of time , i feel a little bit of numbing , um , i try to shake out my arms a little bit . um , just to kind of relieve that um , sensation .
[doctor] okay . all right , and i know that you've had this also , had this history of gout . and the last episode you had was about three months ago . you had some inflammation of your toe . have you had any other issues with that ?
[patient] no , i have n't . um , the medication you gave me really controlled it , and i have n't seen a flare-up since .
[doctor] okay . all right , and how are you doing with your psoriasis ?
[patient] that's been under control too . that has n't been a- a major problem for me either .
[doctor] okay . i- i know that we had given you some clobetasol for your scalp . is that- so that's doing okay ?
[patient] yeah , that's doing a lot better .
[doctor] okay , great . um , all right , well , i'd like to go ahead and do a physical exam on you .
[patient] okay .
[doctor] let's first look at your vital signs . hey , Sarah , show me the vital signs . great , so everything looks good from that perspective . um , so looking at you , i do n't appreciate any cervical lymphadenopathy . your heart is a nice regular rate and rhythm , and your lungs sound really clear . on your right elbow , you do have some edema and inflammation of your right olecranon and there's some tenderness and an effusion right there . so um , does that hurt when i press it ?
[patient] yeah , that does hurt .
[doctor] okay , and when i turn your arm , do you have pain ?
[patient] yeah , that hurts a bit too .
[doctor] okay , so she has pain- to palpation of the olecranon bursa and pain with pronation and supination . and when you flex- and when you bend it and straighten it , does that hurt ?
[patient] yeah , it does and it's a bit stiff too .
[doctor] okay , so pain with flexion and extension of the right arm . uh , your abdomen is nice and soft , and there's no lower extremity edema . uh , let's go ahead and take a look at some of your labs . you know , you have a lot of arthritis for someone so young , so we had sent off that autoimmune panel . hey , Sarah . show me the autoimmune labs . hey , Sarah . show me the autoimmune profile . hey , Sarah . show me the esr . okay , so that's good . hey , Sarah . show me the uric acid . okay . all right , well , good . that's great . so , you know , it does n't look like you have any systemic arthritis , or sys- systemic inflammatory in process going on . so , my impression of you at this time is that from a gout standpoint , everything is nice and stable . i think that we should continue you on the colchicine 0.6 milligrams twice a day as needed for flare-ups of your gout . um , and then for your osteoarthritis , i'd like to go ahead and order a right elbow x-ray . hey , Sarah . order a right elbow x-ray , and then i'd like to prescribe some meloxicam 15 milligrams once a day for the pain and the swelling .
[patient] okay .
[doctor] hey , Sarah . order meloxicam 15 milligrams once a day . and then i'd like to um , just see those- how- the x-ray show- shows up and the results of that before we refer you for any type of physical therapy , okay ?
[patient] okay .
[doctor] and then from a psoriasis standpoint , i think everything is stable . we'll continue you on the steroid cream for your scalp , okay ?
[patient] that sounds good .
[doctor] all right , do you have any questions ?
[patient] no , that's it .
[doctor] all right , take care .
[patient] thank you .
[doctor] hey , Sarah . finalize the note .

CHIEF COMPLAINT

Follow-up of chronic problem.

HISTORY OF PRESENT ILLNESS

Ms. Carolyn Garcia is a 49-year-old female who presents to the clinic today for follow-up of her chronic problem.

The patient reports her osteoarthritis has been flaring up a little lately, and she would like to talk about that, primarily in her elbows. She states she has been sitting at the computer more in the office, so she is unsure if it is stagnant in that position all day. She notes her right elbow bothers her more than her left elbow, but she is primarily typing all day versus writing. She denies any other joint pain. She notes occasional numbness and tingling in her hands, which she tries to shake out her arms to relieve the numbness.

She also has a history of gout. Her last episode was about 3 months ago. She had some inflammation of her toe at that time. She denies any other issues with that. She states the medication she was given at that time helped with her gout and she has not seen a flare up since. She reports her psoriasis is under control and has not been a major problem for her either. She is still on colchicine 0.6 mg twice a day as needed for flare-ups of her gout.

REVIEW OF SYSTEMS

• Musculoskeletal: Endorses joint pain.
• Neurological: Endorses numbness and tingling.

PHYSICAL EXAMINATION

• Neck: Supple without lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm.
• Gastrointestinal: Abdomen is soft.
• Musculoskeletal: No edema to the lower extremity. Examination of  the right elbow, there is some edema and inflammation of the right olecranon. Some tenderness to palpation of the olecranon bursa. Pain with pronation and supination. Pain with flexion and extension of the right arm.

ASSESSMENT AND PLAN

A 49-year-old female here today for followup of chronic problem.

1. Gout
• Medical Treatment: Continue colchicine 0.6 mg twice a day as needed for flare ups.

2. Osteoarthritis
• Medical Treatment: We will order a right elbow x-ray. We will prescribe meloxicam 15 mg once a day for pain and swelling.

3. Psoriasis
• Medical Treatment: Continue steroid cream.

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