[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.
 
 