[doctor] we're gon na go right to the front- . so when you touch that- hi , michelle , how are you ?
[patient] i'm good . how are you ?
[doctor] i'm good . so i know the nurse told you about dax . i'd like to dax a little bit about you , okay ?
[patient] okay .
[doctor] all right . so , michelle is a 31-year-old female with a past medical history of type 2 diabetes and hypertension who presents with abnormal lab finding . so , michelle , it came back to me that you had had a positive long ... lyme titer .
[patient] yeah .
[doctor] and so , uh , can you , you , you know , can you tell me a little bit about it ? i know the last time i saw you , you had had an insect bite , and you know , it came back positive for lyme . so how are you feeling ?
[patient] i've been feeling ... i could feel better . um ... i've been feeling tired , um , really lacking a lot of energy , and i have swollen joints in my elbows , just really hurts .
[doctor] okay . all right . and have you had any , any body aches ?
[patient] yeah , i have .
[doctor] okay . all right . um , and i know that you were out hiking in the woods and , and that type of thing a couple of weeks ago , and we thought that that's where you got the bite . so , um , how's your , how's your appetite ? have you been okay ? a little nauseous ?
[patient] yeah , i've been a little nauseous . i have n't been able to eat much . i've been trying just to keep , you know , toast and crackers and that's all about i've been able to stomach , really .
[doctor] okay , and , and i know that you had had that , that , uh , bite there . have you noticed any other rash anywhere else ?
[patient] yeah , i have .
[doctor] okay . all right . sometimes they kind of describe it as looking as like a bull's-eye .
[patient] yes .
[doctor] is that what it looked like ?
[patient] mm-hmm .
[doctor] okay . all right . well , um , have you had any , any high fevers ?
[patient] uh , no , not that i've noticed .
[doctor] all right . um , and how about from a diabetes standpoint ? how ... how's your blood sugar been running ? especially now that you kind of have this , like , acute thing going on ? have your blood sugars been okay ?
[patient] they've been okay . i've noticed that they sometimes get a little high and a little low . um , but nothing too far out of range .
[doctor] okay . all right . um , and you're still taking the metformin ?
[patient] yes .
[doctor] okay . all right . good . and then in terms of your high blood pressure , are you monitoring the blood pressures at home ?
[patient] yeah , i , i have a ... i bought a cuff last year , and i've been , um , taking it myself at home . those have looked good . i've been staying away from the salty foods .
[doctor] mm-hmm .
[patient] um , so that's been good .
[doctor] okay . and , um , so you're still taking the lisinopril ?
[patient] yes .
[doctor] okay , great . all right , well , you know , i know that you did the review of systems sheet when you checked in , and i know that you're endorsing some nausea and some joint pain and some body aches . any other symptoms ? abdominal pain ? diarrhea ? anything like that ?
[patient] no , nothing like that .
[doctor] okay . um , so let's go ahead , and we'll ... i'm gon na do a quick physical exam .
[patient] okay .
[doctor] hey , Sarah , show me the vital signs . so i'm looking here at your vital signs . they look great . you do n't have a fever at that ... at this time , so that's really encouraging . i'm just gon na check you out , and , uh , i'm gon na listen to your heart and lungs and look for any rashes and let you know what i find , okay ?
[patient] okay .
[doctor] okay , so on physical examination , you know , you do have some swelling of your , uh , elbow joints bilaterally . um , does it hurt when i touch them ?
[patient] yeah , it does .
[doctor] okay , so she has pain to palpation to both elbow joints . um , and on your skin examination , you do have a bull's-eye rash on your , um , abdomen on the left-hand side . um , it's , it's warm to palpation . any pain with that ?
[patient] no , no pain for that .
[doctor] non-tender to palpation , no evidence of cellulitis . um , and the rest of , you know , the rest of your exam is pretty normal , okay ? so let me just go over some of the results with you , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the lyme titer . so you can see here , you know , in reviewing the results of your lyme titer , it is elevated . so we're gon na go ahead and do some further testing , but we're gon na , you know , we're gon na look into that , okay ?
[patient] okay .
[doctor] hey , Sarah , show me the labs . and in reviewing the results of your labs , everything else looks good . so again , you know , you do n't have an elevated white blood cell count or anything like that . so i think we got this early enough , and we can go ahead and , and treat it , okay ?
[patient] okay .
[doctor] so i wan na talk a little bit about , you know , my assessment and my plan for you . so for your first problem , this newly diagnosed lyme disease , i wan na go ahead and prescribe you doxycycline , 100 milligrams twice a day . you have to take it for three weeks , okay ?
[patient] okay .
[doctor] i'm gon na just touch base with an infectious disease doctor to make sure that there's not anything else that we need to do , okay ? and i wan na see you again next week for a follow-up for this , okay ?
[patient] okay .
so for your second problem , your type 2 diabetes , i wan na go ahead and order a hemoglobin a1c and just this ... make sure we do n't have to make any changes to the metformin , okay ?
[patient] okay .
[doctor] hey , Sarah , order a hemoglobin a1c . and for your last problem , your high blood pressure . it looks today like everything is fine . i think you're doing a really good job of managing your hypertension , and i'm going to continue you on the lisinopril , 10 milligrams a day , and i'm gon na go ahead and order a lipid panel , and , um , i want you to continue to record your blood , blood pressure regularly , okay ?
[patient] okay .
[doctor] all right . do you need a refill of that ?
[patient] uh , yes , i do .
[doctor] okay . hey , Sarah , order lisinopril , 10 milligrams daily . do you have any questions ?
[patient] no , i do n't .
[doctor] okay , so i'm gon na , you know , the nurse is gon na come in , and she's gon na check you out , and then we'll make a follow-up appointment for you , okay ?
[patient] okay .
[doctor] hey , Sarah , finalize the note .
CHIEF COMPLAINT

Abnormal labs.

HISTORY OF PRESENT ILLNESS

The patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs. She had an insect bite at her last visit after hiking in the woods. We drew a Lyme titer which came back positive.

The patient reports she has been feeling tired and lacking a lot of energy. She also notes swollen elbow joints, body aches, bullseye rash, and nausea. She states she has not been able to eat much. What she does eat has been bland foods such as crackers. She denies any high fevers.

Regarding her type 2 diabetes, she states her blood sugars have been okay. She notes they are sometimes a little high or low, but nothing too far out of range. She is still taking metformin.

Regarding her hypertension, she is monitoring her blood pressure at home and it has been good. She is avoiding salty foods and is still taking lisinopril.

The patient denies abdominal pain and diarrhea.

REVIEW OF SYSTEMS

• Constitutional: Denies fevers. Endorses fatigue.
• Gastrointestinal: Denies abdominal pain and diarrhea. Endorses nausea.
• Musculoskeletal: Endorses bilateral elbow joint swelling, pain. Endorses body aches.
• Integumentary: Endorses a rash.

PHYSICAL EXAMINATION

• Gastrointestinal: Examination of her abdomen reveals warmth to palpation. Nontender to palpation. No evidence of cellulitis.
• Musculoskeletal: Swelling and pain to palpation of elbow joints bilaterally.
• Integumentary: Small bullseye rash on the left abdominal quadrant.

RESULTS

Lyme titer: elevated.

Labs: WBC is within normal limits. All other labs are normal as well.

ASSESSMENT AND PLAN

The patient is a 31-year-old female with a past medical history significant for type 2 diabetes, and hypertension who presents with abnormal labs.

Newly diagnosed Lyme disease.
• Medical Reasoning: This is a new issue for her. She presented with an insect bite at her last visit, and her subsequent lyme titer was elevated.
• Medical Treatment: I am going to prescribe doxycycline 100 mg twice a day for 3 weeks. I am going to touch base with an infectious disease doctor to ensure nothing else that needs to be done. I want to see her again next week for follow-up for this.

Hypertension.
• Medical Reasoning: This has been well-controlled based on home monitoring. She has been compliant with dietary modifications including limiting her sodium intake.
• Additional Testing: I am going to order a lipid panel.
• Medical Treatment: She will continue lisinopril 10 mg a day. This was refilled today.
• Patient Education and Counseling: I advised the patient to continue to regularly monitor her blood pressures at home.

Diabetes type 2.
• Medical Reasoning: She has noticed intermittent elevations of her blood glucose levels but has been compliant with the use of metformin. Her diet has been limited due to nausea in the setting of Lyme disease.
• Additional Testing: I am going to order a hemoglobin A1c to ensure no medication changes are needed.

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