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      Below is an instruction that describes a task. Write a response that appropriately completes the request. 
      Identify the problems in the clinical note and for each problem, write a brief assessment. here are the inputs Encounter Date: 11/09/2020

Patient
Name [REDACTED] (68yo, F) ID# Appt. Date/Time 11/09/2020 12:00PM
3380
DOB 10/22/1952 Service Dept. ZANJABEE - WOBURN
Provider BASMAA ALI, MD
Insurance Med Primary: MEDICARE-MA (MEDICARE)
Insurance # : 8GW0UU6FX24
Med Secondary: BCBS-MA
Insurance # : XXM981796798
Policy/Group # : 991767925
Prescription: DST PHARMACY SOLUTIONS DIRECT - Member is eligible. details
Chief Complaint
fatigue, Pre prep visit discussed, Initial Visit
diagnosed by 3 alternative doctors brain tape worm or parasite
fatigue, poor sleep, low appetite, poor memory, numbness, terrible headaches, diagnosed with encephalitis
This appointment is telehealth and was done with real audio despite multiple tries by Dr Ali to connect to the
patient via video also. In the end, we decided to do phone call since pt could not figure out doxy or facetime. Amy
Benison and/or Sarah Clancy helped set up the visit and did the pre-visit planning with the patient.
Patient's Pharmacies
WALGREENS DRUGSTORE #18415 (ERX): 15 BOLTON STREET, READING, MA 01867, Ph (781) 942-5810,
Fax (781) 942-1457
Vitals
None recorded.
Allergies
Reviewed Allergies
NKDA
sensitive to fragrances
Medications
Reviewed Medications[REDACTED] (id #3380, dob: 10/22/1952) Page 10/24
Ambien 11/09/20 entered
nightly
clonazePAM 1 mg tablet 10/29/20 filled
1-2 tablets at bedtime
dextroamphetamine-amphetamine 10 mg tablet 10/27/20 filled
TK 1 T PO BID
Maxalt 10 mg tablet 09/01/20 entered
Take 1 tablet(s) as needed by oral route.
Internal Note: PRN
ondansetron 4 mg disintegrating tablet 09/01/20 filled
PRN
oxyCODONE 5 mg tablet 11/06/20 filled
3-4 times a day
Internal Note: typically morning, noon and night
zolpidem 5 mg tablet 09/01/20 entered
Take 1 tablet(s) every day by oral route.
brain support vitamins
Problems
Reviewed Problems
Chronic pain syndrome - Onset: 11/09/2020
Fatigue - Onset: 11/09/2020
Family History
Reviewed Family History
Maternal Grandmother - Family history of cancer
Maternal Grandfather - Family history of cancer
Paternal Grandmother - Family history of cancer
Paternal Grandfather - Family history of cancer
Father - Heart disease
Mother - Family history of cancer

• breast cancer
  Brother - Alcoholism
  Social History
  Reviewed Social History
  General IM Female
  Education: 12
  Marital status: Divorced
  Diet: Gluten free (Notes: low sugar)
  Exercise level: Occasional
  Tobacco Smoking Status: Former smoker (Notes: quit late nineties)
  Alcohol intake: None
  Caffeine intake: Moderate
  Illicit drugs: none
  General stress level: High
  Significant life stressors: (Notes: health, family, chronic pain)
  Stress Management - How do you manage stress?: read, walks
  Quality of sleep: very poor (Notes: takes many things at night to try to help her sleep)
  Hobbies/Interests: chronic pain stops her
  Seat belts used routinely: N
  Sunscreen used routinely: N
  Smoke alarm in home: Y
  Pap Smear: around 2018
  Mammogram: around 2018
  Colon Cancer Screening: at 50
  Living Situation - Lives with whom, nearby support, guage for loneliness: alone (Notes: feels safe)
  Hard of hearing or deaf in one or both ears?: N
  PHQ9 score: (Notes: no energy because of chronic pain)
  Do you have >6 drinks on any night of the week?: N[REDACTED] (id #3380, dob: 10/22/1952) Page 11/24
  Do you have >6 drinks on any night of the week?: N
  Sexual orientation : Straight or heterosexual
  Surgical History
  Reviewed Surgical History
  breast implant in 1983, ruptured and removed 1992
  GYN History
  Reviewed GYN History
  If Post Menopausal, Age at Menopause: 50.
  Current Birth Control Method: None (Notes: not s.a.).
  Menses Monthly: N.
  Age at Menarche: 13.
  Obstetric History
  Reviewed Obstetric History
  TOTALFULLPREAB. IAB. SECTOPICSMULTIPLELIVING
  2 1
  Past Medical History
  Reviewed Past Medical History
  other: Y - chronic fatigue chronic facial and head pain
  acupuncture - how many session, where, for what?: Y
  arthritis: Y
  asthma: Y
  back pain: Y
  cancer: Y - skin and L lung
  headache: Y
  heart murmur: Y
  hyperthyroidism: Y
  hypothyroidism: Y
  Screening
  None recorded.
  HPI
  68 F has a long standing history of headaches which have now generalized to her entire body. She believes that
  her HA is caused by a brain parasite possibly a tape worm.
  She thinks she has had exposure to molds which have changed her immune system which then allowed her to get
  parasites into her brain.
  Pt has breast implants which burst and were subsequently removed and she thinks the implants did lasting
  damage to her body but is not able to specify it further.
  She wants a doctor who would do a lumbar puncture and look for parasites. She has already had a lumbar
  puncture which showed nl CSF.
  ROS
  Patient reports fatigue but reports no fever, no significant weight gain, no significant weight loss, no exercise
  intolerance, (normal) sleep, and (normal) appetite; pain all over the body.. She reports no dry eyes, no
  irritation, and no vision change. She reports no difficulty hearing and no ear pain. She reports no frequent
  nosebleeds and no nose/sinus problems. She reports no sore throat, no bleeding gums, no snoring, no dry mouth,
  no mouth ulcers, no oral abnormalities, and no teeth problems. She reports no chest pain, no arm pain on
  exertion, no shortness of breath when walking, no shortness of breath when lying down, no palpitations, and no
  known heart murmur. She reports no cough, no wheezing, no shortness of breath, and no coughing up blood. She
  reports no abdominal pain, no vomiting, no diarrhea, and not vomiting blood. She reports no incontinence, no
  difficulty urinating, no hematuria, and no increased frequency. She reports no muscle aches, no muscle weakness,
  no arthralgias/joint pain, no back pain, and no swelling in the extremities. She reports no abnormal mole, no
  jaundice, and no rashes. She reports no loss of consciousness, no weakness, no numbness, no seizures, no
  dizziness, and no headaches. She reports no depression, no sleep disturbances, feeling safe in relationship, and
  no alcohol abuse. She reports no swollen glands and no bruising. She reports no runny nose, no sinus pressure, no
  itching, no hives, and no frequent sneezing.
  Physical Exam
  Patient is a 68-year-old female.
  no exam done. this was a phone call.
  Assessment / Plan
  68 F has a chronic pain syndrome as well as mental illness that does not allow her to have deeper insight into her
  illness.
  I spent 25 minutes trying to suggest that parasites as a cause of any disease in the US was very rare and would[REDACTED] (id #3380, dob: 10/22/1952) Page 12/24
  I spent 25 minutes trying to suggest that parasites as a cause of any disease in the US was very rare and would
  have caught on the numerous tests pt has had done.
  I gave her names of alternative practitioners at Kripalu and the integrative medicine clinic at Canyon Ranch and
  wished her best of luck with her health
  Given that I could not be of further help in fiding a parasite inside her head, pt and I agreed that I could be of no
  further service to her.

1. Fatigue
   R53.83: Other fatigue
2. Chronic pain syndrome
   G89.4: Chronic pain syndrome
   Return to Office
   None recorded.
   Encounter Sign-Off

model
Here are the inputs Vitals: Not Mentioned. Allergies: Reviewed Allergies; NKDA; sensitive to fragrances; Patient's Pharmacies: WALGREENS DRUGSTORE #18415 (ERX): 15 BOLTON STREET, READING, MA 01867, Ph (781) 942-5810, Fax (781) 942-1457. Past Medical History: Reviewed Past Medical History; other: Y - chronic fatigue chronic facial and head pain; acupuncture - how many session, where, for what?: Y; arthritis: Y; asthma: Y; back pain: Y; cancer: Y - skin and L lung; heart murmur: Y; hyperthyroidism: Y; hypothyroidism: Y; hypertension: Y; kidney disease: Y; migraine: Y; osteoporosis: Y. Social History: Reviewed Social History; General IM Female; Education: 12; Marital status: Divorced; Diet: Gluten free (Notes: low sugar); Exercise level: Occasional; Tobacco Smoking Status: Former smoker (Notes: quit late nineties); Alcohol intake: None; Caffeine intake: Moderate; Illicit drugs: none; General stress level: High; Significant life stressors: (Notes: health, family, chronic pain); Stress Management - How do you manage stress?: read, walks; Hobbies/Interests: chronic pain stops her; Seat belts used routinely: N; Sunscreen used routinely: N; Smoke alarm in home: Y; Living Situation - Lives with whom, nearby support, guage for loneliness: alone (Notes: feels safe); Hard of hearing or deaf in one or both ears?: N; PHQ9 score: (Notes: no energy because of chronic pain); Do you have >6 drinks on any night of the week?: N; Sexual orientation : Straight or heterosexual; Surgical History: Reviewed Surgical History; breast implant in 1983, ruptured and removed 1992; GYN History: Reviewed GYN History; If Post Menopausal, Age at Menopause: 50. Past Medical History: Past Medical History not reviewed (last reviewed 09/27/2017); other: Y - chronic fatigue chronic facial and head pain; acupuncture - how many session, where, for what?: Y; arthritis: Y; asthma: Y; back pain: Y; cancer: Y - skin and L lung; heart murmur: Y; hyperthyroidism: Y; hypothyroidism: Y; hypertension: Y; kidney disease: Y; migraine: Y; osteoporosis: Y. Social History: Social History not reviewed (last reviewed 09/27/2017); General Stress level: High; Significant life stressors: (Notes: health, family, chronic pain); Stress Management - How do you manage stress?: read, walks; Hobbies/Interests: chronic pain stops her; Seat belts used routinely: N; Smoke alarm in home: Y; Living Situation - Lives with whom, nearby support, guage for loneliness: alone (Notes: feels safe); Hard of hearing or deaf in one or both ears?: N; PHQ9 score: (Notes: no energy because of chronic pain); Do you have >6 drinks on any night of the week?: N; Sexual orientation : Straight or heterosexual; Marriage and Civil Unions: Divorced; Education: 12; Marital status: Divorced; General IM Female; Exercise level: Occasional; Tobacco Smoking Status: Former smoker (Notes: quit late nineties); Alcohol intake: None; Caffeine intake: Moderate; Illicit drugs: none; General stress level: High; Significant life stressors: (Notes: health, family, chronic pain); Stress Management - How do you manage stress?: read, walks; Hobbies/Interests: chronic pain stops her; Seat belts used routinely: N; Smoke alarm in home: Y; Living Situation - Lives with whom, nearby support, guage for loneliness: alone (Notes: feels safe); Hard of hearing or deaf in one or both ears?: N; PHQ9 score: (Notes: no energy because of chronic pain); Do you have >6 drinks on any night of the week?: N; Sexual orientation : Straight or heterosexual; Marriage and Civil Unions: Divorced; Education: 12; Marital status: Divorced; General IM Female; Occupation: (Notes: N/A); General IM Female; Diet: (Notes: GFF and low sugar); Exercise level: Occasional (Notes: occasional walking, swimming); Tobacco Smoking Status: Former smoker (Notes: quit late 90s); Alcohol intake: None; Caffeine intake: Moderate; Illicit drugs: none; General stress level: High; Significant life stressors: (Notes: health, family, chronic pain); Stress Management - How do you manage stress?: (Notes: none); Hobbies/Interests: reading); Seat belts used routinely: N; Smoke alarm in home: Y; Living