[doctor] hi , vincent . how are you ? [patient] i'm good . how about you ? [doctor] i'm good . so le- are you ready to get started ? [patient] i am . [doctor] okay . vincent is a 56-year-old male here with abnormal lab findings . so , i've heard you were in the er , vincent , and they found that you had a low hemoglobin . [patient] yup . [doctor] were you having some dizziness and some lightheadedness ? [patient] i was very lightheaded . i- i do n't know . very lightheaded . [doctor] okay . and have you noticed bleeding from anywhere ? [patient] i have not . i have n't hurt myself in quite a while . maybe a slight nick from a knife while chopping some onions , but nothing more than that . [doctor] but no blood in your stools or- [patient] no . [doctor] . anything like that ? [patient] no . [doctor] okay . and any type of weight loss or decreased appetite or night sweats ? coughs ? [patient] uh , s- slightly decreased appetite , but i wish i had some weight loss . [doctor] um , okay . and how about any abdominal pain ? fever , chills ? [patient] uh , none of that . [doctor] okay . all right . um , any nausea or vomiting ? [patient] not really . yeah . maybe a bit of nausea . [doctor] okay . [patient] i- sitting at the back of a car , that makes me nauseous at times . [doctor] okay . all right . um , well , how are you doing in terms of your knee replacement . i know you had that done last year . that's going okay ? [patient] mm , it seems okay . yeah . [doctor] okay . you're walking around without a problem ? [patient] yup , yup . just not good enough to run yet , but everything else works just fine . [doctor] all right . um , and i know a few years ago , you had , had that scare with the possible lung cancer , but then they did the biopsy and , and you've been fine . [patient] yup , yup . all good . [doctor] turned out to be benign . [patient] yup . [doctor] okay . great . all right . well , let's go ahead and do a quick physical exam . so looking at you , you do n't appear in any distress . your heart is regular . your lungs sound nice and clear . you have some tenderness to the right lower quadrant to palpation of your abdomen . your lower extremities have no edema . [doctor] um , all right . well , let's go ahead and look at your labs , okay ? [patient] yup . [doctor] hey , dragon , show me the hemoglobin . yeah , so your hemoglobin is 8.2 , which is quite low for somebody of your height and weight , so we'll have to look into that a , a little bit further . i know that they did the endoscopy in the emergency room . hey , dragon , show me the endoscope results . [doctor] good . so it looks like you had some gastritis , which is just inflammation of your stomach and they also found a slight polyp , which i know that they biopsied and the results are pending at this time . um , so , you may have had some bleeding from the gastritis . it's not usual for people to have bleeding from that . [doctor] um , okay , well , hey , dragon , show me the anemia panel . okay . [doctor] anyway , okay . well , vincent , i think , you know , in terms of , my impression of you is that you've had this newfound anemia and for that , i think that we should go ahead and put you on protonix , 40 milligrams , once a day to help with the gastritis . does that sound okay to you ? [patient] it does . you're the doctor . i do n't know what it is . [doctor] so that's just , uh , what we call a proton pump inhibitor which , uh , helps decrease the amount of acid secreted within your stomach . [patient] got it . makes sense . [doctor] hey , hey , dragon , order protonix , 40 milligrams , once a day . [doctor] and i'd like you to try to cut down on your caffeine 'cause that can also irritate your stomach . try not to take any ibuprofen and try to cut down on any alcohol intake , okay ? [patient] yup , yup . the coffee's the hard part . [doctor] yeah . it always is . how about one , one , one eight-ounce cup a day ? okay ? [patient] sure . [doctor] um , and we'll go ahead and we'll see you in a couple weeks , okay ? [patient] sure thing . [doctor] i'm going through , uh , i'll also order another , uh , cbc on you . hey , dragon , order a complete blood count . [doctor] all right . the nurse will be in soon . it's , you know , settle all that . i'll see you soon . [patient] see you . [doctor] hey , dragon , finalize the note . 
ASSESSMENT AND PLAN

Vincent Young is a 56-year-old male who presents today for lab review.
 
 New found anemia.
 • Medical Reasoning: His hemoglobin was 8.2, which is low for his height and weight. Endoscopy from the hospital showed gastritis which could be the source of bleeding. The endoscopy also showed a polyp and a polypectomy was performed. The pathology is still pending.
 • Patient Education and Counseling: I encouraged the patient to reduce his caffeine consumption avoid NSAIDs and alcohol.
 • Additional Testing: Repeat CBC was ordered.
 • Medical Treatment: I prescribed Protonix 40 mg once a day for gastritis.
 
 