[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 Sarah , 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 Sarah , 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 Sarah , 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 Sarah , finalize the note .
CHIEF COMPLAINT

Annual exam.

HISTORY OF PRESENT ILLNESS

Jerry Nguyen a 54-year-old male with a past medical history significant for osteoporosis, and multiple sclerosis, who presents for an annual exam.

The patient states he has been traveling all over the country. He notes it has been a stressful summer and adjusting to everything in the fall.

The patient reports a lack of sleep. He has tried melatonin, meditation, and stretching every morning, but nothing has helped.

For treatment of his osteoporosis, he is on Fosamax. He denies any issues with his joints. He denies any recent broken bones.

Regarding his multiple sclerosis, he last saw the neurologist 6 months ago. He is taking his medication and denies any issues with this. Previously, he experienced right leg weakness, however, this has resolved.

He does have some lingering issues with his right knee after previous surgery, but nothing out of the ordinary.

The patient denies any chest pain or shortness of breath.

REVIEW OF SYSTEMS

• Cardiovascular: Denies chest pain or dyspnea.
• Respiratory: Denies shortness of breath.
• Musculoskeletal: Endorses right knee discomfort.
• Neurological: Endorses insomnia.

PHYSICAL EXAMINATION

• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Musculoskeletal: Weakness in the lower extremities, 4/5 on the right and 3/5 on the left. Reflexes are good. Arthritic changes in the right knee.

RESULTS

X-ray of the right knee demonstrates some arthritic changes.

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.

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