[doctor] hi andrea , how are you ? [patient] i'm doing well . how are you ? [doctor] doing well . uh , so i know the nurse told you about dax . i'd like to tell dax a little bit about you . okay ? [patient] okay . [doctor] so , andrea is a 52-year-old female with a past medical history significant for rheumatoid arthritis , atrial fibrillation , and reflux who presents today for her annual exam . so andrea , it's been a year since i saw you . how are you doing ? [patient] i'm doing well . so , i've been walking like you told me to and , um , exercising and doing yoga , and that's actually helped with my arthritis a lot , just the- the constant movement . so , i have n't had any joint pain recently . [doctor] okay . good . so , no- no issues with any stiffness or pain or flare ups over the last year ? [patient] no . [doctor] okay . and i know that we have you on the methotrexate , are you still taking that once a week ? [patient] yes , i am . [doctor] okay . and any issues with that ? [patient] no . [doctor] no . okay . and then in terms of your a-fib , how are you doing with that ? are you having any palpitations ? or , i know that you've kind of been in and out of it over the past , you know , year or so . [patient] yeah . i've still been having palpitations . the- the last one i had was about a week ago . i've noticed that when i start to get stressed , um , they start to flare up again . so , i've been trying meditation , trying running with my dog to try and relieve the stress but it has n't really been working . [doctor] yeah . i- i know that you had called , um , last month and we- we did that event monitor for you , uh , which we'll take a look at in a few minutes . okay ? [patient] okay . [doctor] um , how about um , your reflux ? you know , we had placed you on the protonix , uh , has that helped ? and i know that you were gon na do some dietary modifications . [patient] yeah . i cut out soda and that- that's helped- seemed to help , and the medication's been helping too . i have n't had a flare up in over , i think , five months . [doctor] okay . all right . um , so , you know , i know that you did the review of systems sheet when you checked in and , you know , you had- you know , you endorsed the palpitations and you had some nasal congestion . any other symptoms ? you know , chest pain , shortness of breath , nausea or vomiting ? [patient] no , nothing like that . just the nasal- nasal congestion because of my allergies . [doctor] okay . all right . okay . well , i'd like to go ahead and do a quick physical exam , okay ? [patient] okay . [doctor] all right . hey dragon , show me the vital signs . okay . so , you're in- here in the office today , it looks like , you know , your heart rate's really good today . it's- it's nice and controlled so that's good . um , i'm just gon na take a look into your heart and lungs and- and i'll let you know what i find . okay ? [patient] okay . [doctor] okay . so , on physical examination , um , you know , everything looks really good . on your heart examination , i do appreciate a slight 2/6 systolic- systolic ejection murmur , um , which we've heard in the past so i'm not worried at that . you're in the- a nice regular rate and rhythm at this time . your lungs are nice and clear . on your right elbow , i do notice some edema and some erythema . does it hurt when i press it ? [patient] yeah , it does a bit . [doctor] okay . so , she has pain to palpation of the right elbow . um , and you have no lower extremity edema , okay ? um , so i wan na go ahead and just take a look at some of your results . okay ? [patient] okay . [doctor] hey dragon , show me the event- event monitor results . okay . so , you know , this is the results of your event monitor which shows that , you know , you're in and out of a-fib , you have what we call a conversion pause . you know , you're in a-fib , you pause , and then you go back to regular rhythm . so , we'll talk about that , okay ? [patient] okay . [doctor] hey dragon , show me the autoimmune panel . so , looking here at your autoimmune panel , everything looks good , it looks like you're- you know , everything is well controlled with your rheumatoid arthritis on the methotrexate . okay ? so , let me just go over a little bit about my assessment and my plan for you . okay ? [patient] okay . [doctor] so for your first problem , your rheumatoid arthritis , again , everything looks good . i wan na just continue you on the methotrexate 2.5 mg , once weekly . um , and uh , if you need a referral back to see the rheumatologist , let me know , but i think everything seems stable now . do you need a refill of the methotrexate ? [patient] yes , i do . [doctor] okay . hey dragon , order methotrexate , 2.5 mg once weekly . for your second problem , the atrial fibrillation . so , you're going in and out of a-fib and i'd like to just keep you in normal sinus rhythm . so , i wan na go ahead and refer you to cardiology for a cardiac ablation which just maps out where that rhythm is coming from and burns it so it does n't come back . okay ? you're young , we wan na keep you in a normal rhythm and , being that you're going in and out of a-fib , i think that's what we should do . okay ? [patient] okay . [doctor] hey dragon , order a referral to cardiology . and for your last problem , the reflux , you know , i wanna- i want you to just continue on the protonix , 40 mg a day . continue with your dietary modifications , you know , avoiding coffee and spicy foods , that type of thing . okay ? and then let me know if you have any other issues with that , okay ? [patient] will do . [doctor] any questions ? [patient] no , i do n't . [doctor] okay . all right . it was good to see you . [patient] good seeing you . [doctor] hey dragon , finalize the note .
ASSESSMENT AND PLAN

Andrea Roberts is a 52-year-old female with a past medical history significant for rheumatoid arthritis, atrial fibrillation, and reflux, who presents today for her annual exam. It has been a year since she was last seen.
 
 Rheumatoid arthritis.
 • Medical Reasoning: The patient has remained active and has been compliant with methotrexate once weekly. Her recent autoimmune panel was normal.
 • Medical Treatment: She will continue on methotrexate 2.5 mg once weekly. This was refilled today.
 • Specialist Referrals: If she needs a referral back to the rheumatologist, she will let me know.
 
 Atrial fibrillation.
 • Medical Reasoning: She continues to experience episodes of palpitations. Her most recent episode was about 1 week ago. She is in normal sinus rhythm today, but her recent cardiac event monitor demonstrated a conversion pause.
 • Specialist Referrals: We will refer her to cardiology for a cardiac ablation.
 
 GERD.
 • Medical Reasoning: She has been compliant with dietary modifications and denies any episodes in approximately 5 months.
 • Medical Treatment: Continue on Protonix 40 mg daily.
 • Patient Education and Counseling: She could continue with dietary modifications and avoid known dietary triggers.
 
 