DATEXIS/aci_bench_intent_annotated · Datasets at Hugging Face

text stringlengths 14 3.73k	encounter_id stringclasses 207 values	text_id int64 0 69	intents listlengths 1 9	sections listlengths 1 4	doc_only stringlengths 6 3.62k	__index_level_0__ int64 0 5.29k
doctor: alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that patient: nope	D2N047	20	[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment" ]	[ "Assessment", "Plan" ]	alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that	1,300
doctor: okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns patient: alright when is the urologist gon na call me	D2N047	21	[ "Follow-up", "Medication", "Reassessment" ]	[ "Assessment", "Plan" ]	okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns	1,301
doctor: i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week patient: sounds good	D2N047	22	[ "Chitchat" ]	[ "Null" ]	i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week	1,302
doctor: okay alright well great it was good to see you bye i could just hit it and i can just talk and then i'm just	D2N047	23	[ "Chitchat" ]	[ "Null" ]	doctor: okay alright well great it was good to see you bye i could just hit it and i can just talk and then i'm just	1,303
doctor: alright brittany so i see that you are experiencing some right foot pain could you tell me what happened patient: yeah well i was playing tennis and i was trying to you know volley the ball	D2N048	0	[ "Acute Symptoms", "Greetings" ]	[ "Subjective" ]	alright brittany so i see that you are experiencing some right foot pain could you tell me what happened	1,304
doctor: mm-hmm patient: it was like a double game and i was trying to volley the ball and i got in front of another player and actually ended up falling on top of my foot	D2N048	1	[ "Acute Symptoms" ]	[ "Subjective" ]	mm-hmm	1,305
doctor: alright patient: and then yeah it kinda hurt i quickly then twisted my myself around her because i was trying to catch myself but then i started to feel some pain in my foot	D2N048	2	[ "Acute Symptoms" ]	[ "Subjective" ]	alright	1,306
doctor: mm-hmm okay have you ever injured that foot before patient: yeah no sorry i injured my other foot before not this foot	D2N048	3	[ "Personal History" ]	[ "Subjective" ]	mm-hmm okay have you ever injured that foot before	1,307
doctor: okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing patient: yeah that's fine	D2N048	4	[ "Personal History" ]	[ "Subjective" ]	okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing	1,308
doctor: alright were you able to continue playing patient: no i had to stop i actually it was like i had to be held from the field because i could n't put weight on my foot	D2N048	5	[ "Acute Symptoms" ]	[ "Subjective" ]	alright were you able to continue playing	1,309
doctor: i'm sorry okay so what have you been doing for the pain since then patient: i wrapped it after a the game they had some ace wraps in their clubhouse and so i wrapped it up and then i iced it last night and i just kept it up on a pillow and then i took some ibuprofen	D2N048	6	[ "Therapeutic History" ]	[ "Subjective" ]	i'm sorry okay so what have you been doing for the pain since then	1,310
doctor: okay could you one more time when did this injury happen patient: this happened about couple days ago	D2N048	7	[ "Acute Symptoms" ]	[ "Subjective" ]	okay could you one more time when did this injury happen	1,311
doctor: okay so did you say whether does the ibuprofen help at all patient: yeah it helps a little bit but then you know it it you know after a while it wears out	D2N048	8	[ "Therapeutic History" ]	[ "Subjective" ]	okay so did you say whether does the ibuprofen help at all	1,312
doctor: okay and then have you experienced any numb numbness or tingling patient: no no numbness	D2N048	9	[ "Acute Symptoms" ]	[ "Subjective" ]	okay and then have you experienced any numb numbness or tingling	1,313
doctor: okay alright any loss in sensation patient: no i mean i i can still feel like i can still feel my foot	D2N048	10	[ "Acute Symptoms" ]	[ "Subjective" ]	okay alright any loss in sensation	1,314
doctor: okay alright that's good to hear so you were playing tennis is that what you normally do to work out patient: i do i'm trying to learn but i can not afford tennis less lessons so me and my friends just hit the balls back and forth i do sleep	D2N048	11	[ "Other Socials" ]	[ "Subjective" ]	okay alright that's good to hear so you were playing tennis is that what you normally do to work out	1,315
doctor: i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah patient: that scares me	D2N048	12	[ "Chitchat" ]	[ "Null" ]	i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah	1,316
doctor: it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay patient: okay	D2N048	13	[ "Physical Examination" ]	[ "Objective" ]	it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay	1,317
doctor: alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt patient: no uh uh	D2N048	14	[ "Physical Examination" ]	[ "Objective" ]	alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt	1,318
doctor: okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions patient: yeah do i have to do the surgery	D2N048	15	[ "Physical Examination", "Discussion", "Radiology Examination", "Diagnostic Testing", "Acute Assessment", "Other Treatments" ]	[ "Objective", "Assessment", "Plan" ]	okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions	1,319
doctor: so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with patient: i just hate that word surgery doc	D2N048	16	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with	1,320
doctor: so it's actually patient: have to be in the hospital	D2N048	18	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	so it's actually	1,321
doctor: no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed patient: i'm right handed	D2N048	19	[ "Discussion" ]	[ "Plan" ]	no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed	1,322
doctor: yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what patient: i mean	D2N048	20	[ "Discussion" ]	[ "Plan" ]	yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what	1,323
doctor: mm-hmm patient: i really wan na keep on playing my tennis with my friends but	D2N048	22	[ "Discussion" ]	[ "Plan" ]	mm-hmm	1,324
doctor: yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there patient: i suppose so	D2N048	23	[ "Discussion", "Referral" ]	[ "Plan" ]	yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there	1,325
doctor: alright patient: thank you	D2N048	25	[ "Chitchat" ]	[ "Null" ]	alright	1,326
doctor: no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay patient: okay	D2N048	26	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay	1,327
doctor: alright patient: good	D2N048	27	[ "Chitchat" ]	[ "Null" ]	alright	1,328
doctor: thank you patient: thank you	D2N048	28	[ "Chitchat" ]	[ "Null" ]	thank you	1,329
doctor: hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on patient: and i've been in a lot of pain it started about i would say probably about three days ago	D2N049	0	[ "Acute Symptoms", "Personal History", "Greetings" ]	[ "Subjective" ]	hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on	1,330
doctor: okay so is the pain that you're having is it constant or does it come and go patient: it's constant	D2N049	3	[ "Acute Symptoms" ]	[ "Subjective" ]	okay so is the pain that you're having is it constant or does it come and go	1,331
doctor: alright are you able to urinate patient: i am and this morning i actually started seeing some blood	D2N049	5	[ "Acute Symptoms" ]	[ "Subjective" ]	alright are you able to urinate	1,332
doctor: okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes patient: i've had it for probably this might be my third time	D2N049	6	[ "Acute Symptoms" ]	[ "Subjective" ]	okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes	1,333
doctor: third time alright patient: yeah i have n't had one in a while but yeah this is my third time	D2N049	7	[ "Acute Symptoms" ]	[ "Subjective" ]	third time alright	1,334
doctor: okay so have you noticed any nausea chills fever patient: no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous	D2N049	8	[ "Acute Symptoms" ]	[ "Subjective" ]	okay so have you noticed any nausea chills fever	1,335
doctor: okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain patient: yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working	D2N049	9	[ "Acute Symptoms", "Therapeutic History" ]	[ "Subjective" ]	okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain	1,336
doctor: okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved patient: yeah usually usually about about three four days to pass it yeah	D2N049	10	[ "Acute Symptoms" ]	[ "Subjective" ]	okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved	1,337
doctor: right so this is this is the looks like this is the third day patient: yeah	D2N049	11	[ "Acute Symptoms" ]	[ "Subjective" ]	right so this is this is the looks like this is the third day	1,338
doctor: so we are getting close there patient: okay	D2N049	12	[ "Acute Symptoms" ]	[ "Subjective" ]	so we are getting close there	1,339
doctor: yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff patient: i was i have n't been great about taking it but i did get the blood pressure cuff	D2N049	13	[ "Therapeutic History", "Reassessment", "Acute Assessment" ]	[ "Subjective", "Assessment" ]	yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff	1,340
doctor: so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running patient: like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty	D2N049	14	[ "Acute Symptoms" ]	[ "Subjective" ]	so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running	1,341
doctor: okay that i mean that's not too bad i think when you were first diagnosed you were up there in the the one eighties which was really high patient: right	D2N049	16	[ "Acute Symptoms" ]	[ "Subjective" ]	okay that i mean that's not too bad i think when you were first diagnosed you were up there in the the one eighties which was really high	1,342
doctor: so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that patient: trying my best but doc i really like my french fries	D2N049	17	[ "Discussion", "Other Treatments" ]	[ "Plan" ]	so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that	1,343
doctor: we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help patient: yeah some help could be helpful	D2N049	19	[ "Discussion", "Chitchat" ]	[ "Plan" ]	we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help	1,344
doctor: okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright. so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday patient: i have and those those have been pretty good they are like in the low one hundreds	D2N049	20	[ "Reassessment", "Referral", "Medication" ]	[ "Assessment", "Plan" ]	okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright. so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday	1,345
doctor: okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday patient: i do	D2N049	21	[ "Discussion" ]	[ "Plan" ]	okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday	1,346
doctor: that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain patient: no chest pain	D2N049	23	[ "Acute Symptoms", "Physical Examination" ]	[ "Subjective", "Objective" ]	that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain	1,347
doctor: no chest pain are you having any belly pain patient: the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain	D2N049	24	[ "Acute Symptoms" ]	[ "Subjective" ]	no chest pain are you having any belly pain	1,348
doctor: no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt patient: yes	D2N049	25	[ "Acute Symptoms", "Physical Examination" ]	[ "Subjective", "Objective" ]	no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt	1,349
doctor: okay i'm gon na press here on your back is that painful patient: yes	D2N049	26	[ "Physical Examination" ]	[ "Objective" ]	okay i'm gon na press here on your back is that painful	1,350
doctor: alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound patient: that sounds good and i i just i just want this pain to go away so thank you	D2N049	27	[ "Reassessment", "Discussion", "Acute Assessment", "Referral", "Medication" ]	[ "Assessment", "Plan" ]	alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound	1,351
doctor: okay no problem	D2N049	28	[ "Chitchat" ]	[ "Null" ]	doctor: okay no problem	1,352
doctor: hey mason good to see you today so let's see you here in my notes for evaluation of kidney stones your your pcp said you had some kidney stones so you got a referral over so can you tell me a little bit about that you know what happened when did you first notice them patient: yeah it was about you know about a week ago and i was working down in the the barn with the horses and you know i was moving some hay but i developed this real sudden onset of pain in my right back and i thought it initially it was from throwing hay but it i broke out into a sweat i got real nauseated and that's when i went and saw my doctor and he ordered a cat scan and said that i had a kidney stone but you know that's i i've never had that before my father's had them in the past but yeah so that's that's how that all happened	D2N050	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	hey mason good to see you today so let's see you here in my notes for evaluation of kidney stones your your pcp said you had some kidney stones so you got a referral over so can you tell me a little bit about that you know what happened when did you first notice them	1,353
doctor: okay so you said you had the pain on the right hand side does it move anywhere or radiate patient: well when i had it it would it radiated almost down to my groin	D2N050	1	[ "Personal History" ]	[ "Subjective" ]	okay so you said you had the pain on the right hand side does it move anywhere or radiate	1,354
doctor: okay and is the pain constant or does it come and go patient: well when i you know after i found out i had a disk a kidney stone it came a couple times but it did n't last as long no i've been i've been straining my urine they told me to pee in this little cup	D2N050	3	[ "Personal History" ]	[ "Subjective" ]	okay and is the pain constant or does it come and go	1,355
doctor: mm-hmm patient: and i've been straining my urine and you know i do n't see anything in there	D2N050	4	[ "Personal History" ]	[ "Subjective" ]	mm-hmm	1,356
doctor: okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual patient: no not really not really darker	D2N050	5	[ "Vegetative History" ]	[ "Subjective" ]	okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual	1,357
doctor: okay so have you had kidney stones before and then you said your father had them but patient: i've never had a kidney stone my dad had them a lot but i've never had one	D2N050	6	[ "Family History" ]	[ "Subjective" ]	okay so have you had kidney stones before and then you said your father had them but	1,358
doctor: okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means patient: i have a stroke	D2N050	7	[ "Physical Examination" ]	[ "Objective" ]	okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means	1,359
doctor: can you repeat that patient: i did i have a stroke	D2N050	8	[ "Physical Examination" ]	[ "Objective" ]	can you repeat that	1,360
doctor: no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in the proximal right ureter and that's that duct that classes from your your kidney to down to your bladder there is no evidence of hydronephrosis that would mean that the stone is obstruct obstructing the ureter causing swelling in the kidney so there is there is no evidence of that so let's talk a little bit about my assessment and plan so you do have that kidney stone so right now i'm gon na recommend that we we have you push fluids just to help facilitate you urinating and passing the stone i'm gon na prescribe you some oxycodone five milligrams every six to eight hours for pain and you can continue to take tylenol between that for any breakthrough pain and you already have a strainer so that's good continue to use that and we can see continue that until the stone hasses and i'm also gon na order a bmp and your urinalysis and urine culture just to make sure that everything else is okay with you and based on urinalysis we can see if we need to prescribe you antibiotics see if you have any type of infection i do want to see you back in about one to two weeks and hopefully by that time you you passed the stone but if not we can discuss further treatment lithotripsy it's like a shock wave kinda breaks up that stone it's not it's not that invasive procedure but we can just we can discuss that if it has n't passed in that one to two weeks that sound good patient: that sounds perfect dear too	D2N050	9	[ "Follow-up", "Medication", "Radiology Examination", "Diagnostic Testing", "Reassessment" ]	[ "Objective", "Assessment", "Plan" ]	no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in the proximal right ureter and that's that duct that classes from your your kidney to down to your bladder there is no evidence of hydronephrosis that would mean that the stone is obstruct obstructing the ureter causing swelling in the kidney so there is there is no evidence of that so let's talk a little bit about my assessment and plan so you do have that kidney stone so right now i'm gon na recommend that we we have you push fluids just to help facilitate you urinating and passing the stone i'm gon na prescribe you some oxycodone five milligrams every six to eight hours for pain and you can continue to take tylenol between that for any breakthrough pain and you already have a strainer so that's good continue to use that and we can see continue that until the stone hasses and i'm also gon na order a bmp and your urinalysis and urine culture just to make sure that everything else is okay with you and based on urinalysis we can see if we need to prescribe you antibiotics see if you have any type of infection i do want to see you back in about one to two weeks and hopefully by that time you you passed the stone but if not we can discuss further treatment lithotripsy it's like a shock wave kinda breaks up that stone it's not it's not that invasive procedure but we can just we can discuss that if it has n't passed in that one to two weeks that sound good	1,361
doctor: alright patient: thank you document	D2N050	10	[ "Chitchat" ]	[ "Null" ]	alright	1,362
doctor: so i will see you in a week or so and hopefully you've passed that stone and i'll send my nurse in with that prescription patient: okay thank you	D2N050	11	[ "Follow-up" ]	[ "Plan" ]	so i will see you in a week or so and hopefully you've passed that stone and i'll send my nurse in with that prescription	1,363
doctor: thanks	D2N050	12	[ "Chitchat" ]	[ "Null" ]	doctor: thanks	1,364
doctor: hi jeremy how are you patient: i'm really good thank you how are you	D2N051	0	[ "Greetings" ]	[ "Subjective" ]	hi jeremy how are you	1,365
doctor: i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks patient: yes	D2N051	1	[ "Acute Symptoms" ]	[ "Subjective" ]	i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks	1,366
doctor: going away patient: yeah it's been there gosh it's like six or so weeks right now and it's and it's on my right foot and it's just yeah it's just not going away i'm not sure if it maybe even gotten a little worse from when i first noticed it	D2N051	2	[ "Acute Symptoms" ]	[ "Subjective" ]	going away	1,367
doctor: okay and how long did you say it's going on for patient: probably about	D2N051	3	[ "Acute Symptoms" ]	[ "Subjective" ]	okay and how long did you say it's going on for	1,368
doctor: six eight weeks maybe patient: okay and do you have any pain in your foot no no no pain at all okay now i know that you're a diabetic and you are on some insulin have your sugars been running okay yeah they have been running	D2N051	4	[ "Personal History" ]	[ "Subjective" ]	six eight weeks maybe	1,369
doctor: your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine patient: yes it it it definitely was higher than nine	D2N051	6	[ "Acute Symptoms" ]	[ "Subjective" ]	your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine	1,370
doctor: okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or patient: yeah i was you know i think initially i'm you know i was out in the backyard you know kind of you know doing some work and you know i know i you know i could've stepped on a nail or you know there was some other work but you know i'm always outside so i do n't know if that kind of led to anything or caused anything	D2N051	7	[ "Acute Symptoms" ]	[ "Subjective" ]	okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or	1,371
doctor: okay alright and have you had any fever or chills patient: no no no fever or chills you know i kinda you know get headaches pretty often i do n't know if that you know i do n't know if that's a stress or but you know always have like the tension headaches in the front	D2N051	8	[ "Acute Symptoms" ]	[ "Subjective" ]	okay alright and have you had any fever or chills	1,372
doctor: okay and do you have do you have neuropathy where you get like numbing and tingling in your feet patient: occasionally yeah occasionally especially when it's like colder outside	D2N051	9	[ "Acute Symptoms" ]	[ "Subjective" ]	okay and do you have do you have neuropathy where you get like numbing and tingling in your feet	1,373
doctor: mm-hmm kinda feels like it takes a little longer to patient: warm up but yeah i kinda have some sensation in in all my extremities	D2N051	10	[ "Acute Symptoms" ]	[ "Subjective" ]	mm-hmm kinda feels like it takes a little longer to	1,374
doctor: okay alright and then are you are you a smoker or did you smoke patient: i did back you know kind of years ago i did but yeah i have n't smoked anything in in good number of years	D2N051	11	[ "Drug History" ]	[ "Subjective" ]	okay alright and then are you are you a smoker or did you smoke	1,375
doctor: okay alright when did you stop smoking patient: couple years ago maybe four or so years ago	D2N051	12	[ "Drug History", "Drug History" ]	[ "Subjective" ]	okay alright when did you stop smoking	1,376
doctor: okay alright and how many packs a day would you smoke patient: gosh back then yeah was at least two	D2N051	13	[ "Drug History" ]	[ "Subjective" ]	okay alright and how many packs a day would you smoke	1,377
doctor: okay alright how many years did you smoke for like twenty patient: yeah at least twenty yeah twenty plus years	D2N051	14	[ "Drug History" ]	[ "Subjective" ]	okay alright how many years did you smoke for like twenty	1,378
doctor: okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk patient: no no no no pain you know just kind of you know it's just i know that it's there	D2N051	15	[ "Acute Symptoms" ]	[ "Subjective" ]	okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk	1,379
doctor: okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no patient: no no you know it's you know i just kinda feel like i've been just trying to take it easy lately	D2N051	16	[ "Acute Symptoms" ]	[ "Subjective" ]	okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no	1,380
doctor: mm-hmm patient: but yeah most most of the stuff i've been doing is just kind of hanging around the house	D2N051	17	[ "Acute Symptoms" ]	[ "Subjective" ]	mm-hmm	1,381
doctor: okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin patient: i am yes yeah i do the baby aspirin every day	D2N051	18	[ "Therapeutic History", "Personal History" ]	[ "Subjective" ]	okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin	1,382
doctor: okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything patient: okay and do you have a podiatrist for your yearly foot exams	D2N051	19	[ "Acute Symptoms" ]	[ "Subjective" ]	okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything	1,383
doctor: no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here patient: no	D2N051	20	[ "Physical Examination", "Acute Assessment" ]	[ "Objective", "Assessment" ]	no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here	1,384
doctor: there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help patient: any questions	D2N051	21	[ "Discussion", "Acute Assessment", "Referral", "Medication", "Other Treatments" ]	[ "Assessment", "Plan" ]	there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help	1,385
doctor: yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay patient: sure	D2N051	22	[ "Diagnostic Testing", "Referral" ]	[ "Plan" ]	yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay	1,386
doctor: sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay patient: okay perfect	D2N051	23	[ "Reassessment", "Follow-up", "Medication" ]	[ "Assessment", "Plan" ]	sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay	1,387
doctor: alright patient: perfect thank you so much	D2N051	24	[ "Chitchat" ]	[ "Null" ]	alright	1,388
doctor: okay bye	D2N051	25	[ "Chitchat" ]	[ "Null" ]	doctor: okay bye	1,389
doctor: so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you patient: sure i've been having some back pain on my right side it's been lasting for about a week now	D2N052	0	[ "Personal History", "Greetings" ]	[ "Subjective" ]	so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you	1,390
doctor: okay so on the right side so does that pain does it move anywhere or is it just kinda stay in that that one area patient: yeah it's moved down a little bit on to my right lower side a little bit	D2N052	2	[ "Personal History" ]	[ "Subjective" ]	okay so on the right side so does that pain does it move anywhere or is it just kinda stay in that that one area	1,391
doctor: side okay so how would you describe the pain is it constant or is does it come and go patient: it's pretty constant	D2N052	3	[ "Personal History" ]	[ "Subjective" ]	side okay so how would you describe the pain is it constant or is does it come and go	1,392
doctor: okay did you notice any pain when you're urinating i know i know you say you you saw you see blood but any pain with that patient: no no real pain when i'm when i'm peeing at all	D2N052	4	[ "Vegetative History" ]	[ "Subjective" ]	okay did you notice any pain when you're urinating i know i know you say you you saw you see blood but any pain with that	1,393
doctor: okay so have you taken anything i know have you tried like azo or any of that to patient: i took some ibuprofen that helped a little bit	D2N052	5	[ "Therapeutic History" ]	[ "Subjective" ]	okay so have you taken anything i know have you tried like azo or any of that to	1,394
doctor: alright have you noticed any nausea vomiting fever chills patient: i have n't thrown up but i felt a little bit nauseated	D2N052	7	[ "Vegetative History" ]	[ "Subjective" ]	alright have you noticed any nausea vomiting fever chills	1,395
doctor: little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but patient: yeah my my dad had kidney stones i think he has passed a couple of them i'm not quite sure	D2N052	8	[ "Family History" ]	[ "Subjective" ]	little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but	1,396
doctor: alright and have you had any in the past or is this your first one patient: this is my first time i've never had this before	D2N052	9	[ "Personal History" ]	[ "Subjective" ]	alright and have you had any in the past or is this your first one	1,397
doctor: okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that patient: yeah yeah i had some pain over the weekend i saw my pediatrician this morning so they sent me over here they were concerned that i might have a kidney stone	D2N052	10	[ "Personal History" ]	[ "Subjective" ]	okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that	1,398
doctor: okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain patient: not so much but i i got to participate a little bit i opened some eggs i just did n't go run around and find them	D2N052	11	[ "Chitchat" ]	[ "Null" ]	okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain	1,399

doctor: alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that patient: nope

D2N047

20

[ "Discussion", "Medication", "Diagnostic Testing", "Reassessment" ]

[ "Assessment", "Plan" ]

alright for your second problem of your coronary artery disease i wan na go ahead and order an echocardiogram just to follow up on that heart murmur that you had and i wan na go ahead and continue you on the lipitor forty milligrams a day and the aspirin and the metoprolol and i wan na go ahead and order a lipid panel any questions about that

1,300

doctor: okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns patient: alright when is the urologist gon na call me

D2N047

21

[ "Follow-up", "Medication", "Reassessment" ]

[ "Assessment", "Plan" ]

okay and then for your third problem of your diabetes it sounds like you're doing really well let's go ahead and continue you on the metformin a thousand milligrams twice a day we will go ahead and order a hemoglobin a1c to see if we need to make any adjustments to that and i'm gon na see you again in about three to four weeks okay i want you to call me or message me in the patient portal if you have any concerns

1,301

doctor: i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week patient: sounds good

D2N047

22

[ "Chitchat" ]

[ "Null" ]

i'm gon na reach out i'm gon na reach out to them now and see if they can get you in this week

1,302

doctor: okay alright well great it was good to see you bye i could just hit it and i can just talk and then i'm just

D2N047

23

[ "Chitchat" ]

[ "Null" ]

doctor: okay alright well great it was good to see you bye i could just hit it and i can just talk and then i'm just

1,303

doctor: alright brittany so i see that you are experiencing some right foot pain could you tell me what happened patient: yeah well i was playing tennis and i was trying to you know volley the ball

D2N048

0

[ "Acute Symptoms", "Greetings" ]

[ "Subjective" ]

alright brittany so i see that you are experiencing some right foot pain could you tell me what happened

1,304

doctor: mm-hmm patient: it was like a double game and i was trying to volley the ball and i got in front of another player and actually ended up falling on top of my foot

D2N048

1

[ "Acute Symptoms" ]

[ "Subjective" ]

mm-hmm

1,305

doctor: alright patient: and then yeah it kinda hurt i quickly then twisted my myself around her because i was trying to catch myself but then i started to feel some pain in my foot

D2N048

2

[ "Acute Symptoms" ]

[ "Subjective" ]

alright

1,306

doctor: mm-hmm okay have you ever injured that foot before patient: yeah no sorry i injured my other foot before not this foot

D2N048

3

[ "Personal History" ]

[ "Subjective" ]

mm-hmm okay have you ever injured that foot before

1,307

doctor: okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing patient: yeah that's fine

D2N048

4

[ "Personal History" ]

[ "Subjective" ]

okay so right now you're experiencing right leg pain but you have injured your your left leg before is that what i'm hearing

1,308

doctor: alright were you able to continue playing patient: no i had to stop i actually it was like i had to be held from the field because i could n't put weight on my foot

D2N048

5

[ "Acute Symptoms" ]

[ "Subjective" ]

alright were you able to continue playing

1,309

doctor: i'm sorry okay so what have you been doing for the pain since then patient: i wrapped it after a the game they had some ace wraps in their clubhouse and so i wrapped it up and then i iced it last night and i just kept it up on a pillow and then i took some ibuprofen

D2N048

6

[ "Therapeutic History" ]

[ "Subjective" ]

i'm sorry okay so what have you been doing for the pain since then

1,310

doctor: okay could you one more time when did this injury happen patient: this happened about couple days ago

D2N048

7

[ "Acute Symptoms" ]

[ "Subjective" ]

okay could you one more time when did this injury happen

1,311

doctor: okay so did you say whether does the ibuprofen help at all patient: yeah it helps a little bit but then you know it it you know after a while it wears out

D2N048

8

[ "Therapeutic History" ]

[ "Subjective" ]

okay so did you say whether does the ibuprofen help at all

1,312

doctor: okay and then have you experienced any numb numbness or tingling patient: no no numbness

D2N048

9

[ "Acute Symptoms" ]

[ "Subjective" ]

okay and then have you experienced any numb numbness or tingling

1,313

doctor: okay alright any loss in sensation patient: no i mean i i can still feel like i can still feel my foot

D2N048

10

[ "Acute Symptoms" ]

[ "Subjective" ]

okay alright any loss in sensation

1,314

doctor: okay alright that's good to hear so you were playing tennis is that what you normally do to work out patient: i do i'm trying to learn but i can not afford tennis less lessons so me and my friends just hit the balls back and forth i do sleep

D2N048

11

[ "Other Socials" ]

[ "Subjective" ]

okay alright that's good to hear so you were playing tennis is that what you normally do to work out

1,315

doctor: i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah patient: that scares me

D2N048

12

[ "Chitchat" ]

[ "Null" ]

i love it absolutely yeah my dad one time took me to play racquet ball and i learned the very bruisy way that that was n't for me yeah

1,316

doctor: it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay patient: okay

D2N048

13

[ "Physical Examination" ]

[ "Objective" ]

it's it they they move pretty fast i'm not gon na lie alright so if you do n't mind i'm gon na go ahead and do my my physical exam i'm gon na be calling out some of my findings but if you have any questions go ahead stop me let me know but i will be explaining along the way okay

1,317

doctor: alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt patient: no uh uh

D2N048

14

[ "Physical Examination" ]

[ "Objective" ]

alright so i've looked at your vitals and honestly they look great you know your blood pressure i see is one twenty five over seventy that's almost textbook respiratory rate we are seeing you at a smooth eighteen excuse me your temperature you're running normal ninety seven . one you're you're satting at a hundred percent so and then your pulse so that's interesting like you're you're going at like about sixty beats a minute so i think they're i think we're doing pretty well i'm gon na go ahead and listen to your heart on your heart exam i do n't appreciate any like murmur rub or gallop we have a nice regular rate and rhythm for your lung exam i do appreciate a little bit of stridor that's really interesting but i do n't hear any wheezes or rales so that's great for your i know this sounds weird but for your abdominal exam i do n't appreciate any rebound no guarding on your skin exam i do n't sorry like on your your head everything looks symmetrical your your mucosal membranes are normal you do n't feel hot to touch so that's great but i'm gon na do my foot exam okay so on the right foot there is some bruising of the plantar and dorsal aspects of the foot there is associated swelling when i touch on your midfoot here does it hurt

1,318

doctor: okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions patient: yeah do i have to do the surgery

D2N048

15

[ "Physical Examination", "Discussion", "Radiology Examination", "Diagnostic Testing", "Acute Assessment", "Other Treatments" ]

[ "Objective", "Assessment", "Plan" ]

okay alright tenderness to palpation of the midfoot and positive piano key test of the first and second metatarsals alright it's also warm to touch alright so on your neurovascular exam of your right foot your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch your left foot exam is normal capillary refill is appropriate pedal pulses are strong and sensation is intact so i know that before here we before i came in that we got an x-ray so i've reviewed the results of your x-ray of your right foot and it showed subtle dorsal displacement of the base of the second metatarsal with a three millimeter separation of the first and second metatarsal bases and the presence of a bony fragment in the lisfranc joint space alright i know those were a bunch of fancy words so now i'm gon na explain to you what that all means for my impression and plan your first problem is right foot pain consistent with a lisfranc fracture which is a fracture to one of your second metatarsal bones near the top of your foot right so the big part of your toe is the first metatarsal the second part where you can kinda like bend it right that's the that's the metatarsal that we're talking about based on your exam and what i'm seeing on your x-ray i am gon na recommend surgery for your foot the surgery will help place the bones in their proper positions using plates and screws to help prevent further complications there are also many ligaments at the top of your foot so i will be ordering an mri to further assess the fracture and any injury to the ligaments i know this is a lot do you have any questions

1,319

doctor: so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with patient: i just hate that word surgery doc

D2N048

16

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

so i'm recommending it as there can be significant complications to your foot if you do n't it can lead to poor bone alignment or poor ligament healing which can lead to you losing the arch of your foot and becoming flat-footed you can also develop arthritis in that foot so yes i i i highly recommend it if you want to be able to walk and move about in a way that you are familiar with

1,320

doctor: so it's actually patient: have to be in the hospital

D2N048

18

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

so it's actually

1,321

doctor: no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed patient: i'm right handed

D2N048

19

[ "Discussion" ]

[ "Plan" ]

no no no no no it's actually a day surgery and you'll be able to go home the same day and then you will follow up with me here in the clinic in about a week you'll be in a cast and you will use crutches as you will not be able to use that foot for six to eight weeks after that you'll start gradually walking on your foot based on how you do so the procedure itself is not very long you will and so like since you will be able to go home that's great but you wo n't be able to drive especially since you're saying are you left handed or right handed

1,322

doctor: yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what patient: i mean

D2N048

20

[ "Discussion" ]

[ "Plan" ]

yeah so your your right foot is probably your dominant one and the also the one you're supposed to drive with so no you're gon na you're gon na need somebody to take you home but what

1,323

doctor: mm-hmm patient: i really wan na keep on playing my tennis with my friends but

D2N048

22

[ "Discussion" ]

[ "Plan" ]

mm-hmm

1,324

doctor: yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there patient: i suppose so

D2N048

23

[ "Discussion", "Referral" ]

[ "Plan" ]

yeah so unfortunately yes it does mean that you're out for the rest of the season but hopefully we can get you a great get you to a set up well for next season and in the meantime i think i'm gon na recommend after surgery that we get you to physical therapy i think that that's gon na be a really great way to like kinda strengthen the muscles and make sure that you're at peak performance before we put you back out there

1,325

doctor: alright patient: thank you

D2N048

25

[ "Chitchat" ]

[ "Null" ]

alright

1,326

doctor: no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay patient: okay

D2N048

26

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

no problem so i do wan na let you know that there are some risks associated with any kind of surgical procedure i'm gon na bring you some paperwork and that my ma is gon na go over with you such as like risks of bleeding loss of sensation nerve damage all those things will be discussed with you and if you have any questions leading up to and even after your procedure go ahead and ask them and we'll be more than happy to help with that okay

1,327

doctor: alright patient: good

D2N048

27

[ "Chitchat" ]

[ "Null" ]

alright

1,328

doctor: thank you patient: thank you

D2N048

28

[ "Chitchat" ]

[ "Null" ]

thank you

1,329

doctor: hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on patient: and i've been in a lot of pain it started about i would say probably about three days ago

D2N049

0

[ "Acute Symptoms", "Personal History", "Greetings" ]

[ "Subjective" ]

hey linda good to see you today so looking here in my notes looks like you you think you have a kidney stone think you've had them before and and you i guess you're having some pain and while we are here i see you i see you have a you have past medical history of hypertension diabetes and we will check up on those as well so with your kidney stone can you tell me what happened what's going on

1,330

doctor: okay so is the pain that you're having is it constant or does it come and go patient: it's constant

D2N049

3

[ "Acute Symptoms" ]

[ "Subjective" ]

okay so is the pain that you're having is it constant or does it come and go

1,331

doctor: alright are you able to urinate patient: i am and this morning i actually started seeing some blood

D2N049

5

[ "Acute Symptoms" ]

[ "Subjective" ]

alright are you able to urinate

1,332

doctor: okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes patient: i've had it for probably this might be my third time

D2N049

6

[ "Acute Symptoms" ]

[ "Subjective" ]

okay yeah so and i know you said i see you've had some kidney stones in the past like how many times would you say you've had one of these episodes

1,333

doctor: third time alright patient: yeah i have n't had one in a while but yeah this is my third time

D2N049

7

[ "Acute Symptoms" ]

[ "Subjective" ]

third time alright

1,334

doctor: okay so have you noticed any nausea chills fever patient: no fever some chills and i i just in so much pain i i ca n't eat and i do feel a little nauseous

D2N049

8

[ "Acute Symptoms" ]

[ "Subjective" ]

okay so have you noticed any nausea chills fever

1,335

doctor: okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain patient: yeah i've been taking tylenol i have had to try some ibuprofen i know you said to be careful with my blood pressure but i have been trying to do that because i'm just in so much pain and it's not really working

D2N049

9

[ "Acute Symptoms", "Therapeutic History" ]

[ "Subjective" ]

okay that sound definitely understandable so you've been in a lot of pain so have you tried to take any medications to alleviate the pain

1,336

doctor: okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved patient: yeah usually usually about about three four days to pass it yeah

D2N049

10

[ "Acute Symptoms" ]

[ "Subjective" ]

okay and before what would you how long would you say it took you to pass the other stones or how was that that resolved

1,337

doctor: right so this is this is the looks like this is the third day patient: yeah

D2N049

11

[ "Acute Symptoms" ]

[ "Subjective" ]

right so this is this is the looks like this is the third day

1,338

doctor: so we are getting close there patient: okay

D2N049

12

[ "Acute Symptoms" ]

[ "Subjective" ]

so we are getting close there

1,339

doctor: yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff patient: i was i have n't been great about taking it but i did get the blood pressure cuff

D2N049

13

[ "Therapeutic History", "Reassessment", "Acute Assessment" ]

[ "Subjective", "Assessment" ]

yeah so hopefully we can pass it but we'll i'll definitely we can take a look at it here in a second so while you are here i also wanted to check up on your your diabetes and and hypertension you have so i'm looking here at my notes and you're on two . five of norvasc for your high blood pressure when you came in today your blood pressure was a was a little bit high and i know that's probably because you are in a bunch of pain so that definitely makes sense but i think last time we talked a little bit about you getting a blood pressure cuff and taking your blood pressures regularly so those readings first off were you able to get the blood pressure cuff

1,340

doctor: so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running patient: like the top numbers they're usually the one thirties sometimes i get i do go into one forties and once it went to like one fifty

D2N049

14

[ "Acute Symptoms" ]

[ "Subjective" ]

so the time that you did take it and i think that's something we got to work on is you've taken them i think at least three times a week i would like you to what have those been running

1,341

doctor: okay that i mean that's not too bad i think when you were first diagnosed you were up there in the the one eighties which was really high patient: right

D2N049

16

[ "Acute Symptoms" ]

[ "Subjective" ]

okay that i mean that's not too bad i think when you were first diagnosed you were up there in the the one eighties which was really high

1,342

doctor: so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that patient: trying my best but doc i really like my french fries

D2N049

17

[ "Discussion", "Other Treatments" ]

[ "Plan" ]

so let me talk a little bit also about you trying to lower your salt intake to like like twenty three hundred milligrams a a day so have you been able to do that

1,343

doctor: we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help patient: yeah some help could be helpful

D2N049

19

[ "Discussion", "Chitchat" ]

[ "Plan" ]

we we all like we all like the french fries you know but you know we we we we also do n't like strokes so we do n't want to have a scope and all the all the french fries so that's something definitely i would like you to work on and do you think you'd be able to to curb that french fry habit or that bad this bad food habits by yourself or do you think you need help

1,344

doctor: okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright. so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday patient: i have and those those have been pretty good they are like in the low one hundreds

D2N049

20

[ "Reassessment", "Referral", "Medication" ]

[ "Assessment", "Plan" ]

okay yeah we can definitely get you connected with someone just to help you with your diet kinda that's the biggest thing for a lot of my patient is trying to control that diet alright. so i also want to take a look here at your diabetes and last time you came in your a1c was a little bit higher at seven . three and you're on five hundred of metformin currently so have you been taking your blood sugars before you eat everyday

1,345

doctor: okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday patient: i do

D2N049

21

[ "Discussion" ]

[ "Plan" ]

okay that that that's definitely good because when you came in i think we did a glucose test on you couple of months ago and you were around three hundred which is which is pretty up there so i'm glad that you know those levels are down and have you been taking that metformin everyday

1,346

doctor: that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain patient: no chest pain

D2N049

23

[ "Acute Symptoms", "Physical Examination" ]

[ "Subjective", "Objective" ]

that that that that's really good alright so let me do a quick physical exam on you just a couple of questions before i take a look at your your abdomen and and your back talked to take a look at that that kidney stones you're having so i just want to make sure are you having any any chest pain

1,347

doctor: no chest pain are you having any belly pain patient: the back pain is starting to kind of go down into my groin but i would n't say any back pain i mean abdominal pain

D2N049

24

[ "Acute Symptoms" ]

[ "Subjective" ]

no chest pain are you having any belly pain

1,348

doctor: no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt patient: yes

D2N049

25

[ "Acute Symptoms", "Physical Examination" ]

[ "Subjective", "Objective" ]

no abdominal pain alright so let me check here i'm gon na listen to your heart real quick and so on your heart exam i do hear a grade two out of six systolic ejection murmur and that we knew about that already so not really worried about that currently listen to your lungs your lungs are clear bilaterally i do n't hear any crackles or wheezes so let me press here on your abdomen does that hurt

1,349

doctor: okay i'm gon na press here on your back is that painful patient: yes

D2N049

26

[ "Physical Examination" ]

[ "Objective" ]

okay i'm gon na press here on your back is that painful

1,350

doctor: alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound patient: that sounds good and i i just i just want this pain to go away so thank you

D2N049

27

[ "Reassessment", "Discussion", "Acute Assessment", "Referral", "Medication" ]

[ "Assessment", "Plan" ]

alright so on your examination of your abdomen there is tenderness to palpation of the abdomen there is n't any rebound or guarding though and only there is also cva tinnitus on the right on your on your flank as well and so it seems to me you know that you do have that kidney stone looks like you do have some inflammation around your kidney that's what that that's that tenderness around your cva is is telling me so let's go talk a little bit about my assessment and plan for you so you know right now because of your history of of having kidney stones you you do have a kidney stone so what we're gon na do is first off i'm gon na get you some pain medication kinda you're in a ton of pain right now i'm gon na prescribe you some oxycodone five milligrams you can take that every six to eight hours as needed for pain and so hopefully that can help you feeling better and you can continue to take that tylenol for any breakthrough pain that you're having i do wan na make sure that you're pushing fluids right now because we need to try to push that stone out that you're having just kinda clear your kidneys and that that would definitely help i also want to give you a strainer so you can strain your urine to see if you do actually pass that stone and then i'm going to refer you to urology and we're actually i'm gon na have you you even if you pass a stone in the next couple of days i want you to go anyway because it seems like you're having recurrent kidney stones and so hopefully they can help do something to to help this from happening in the future for your hypertension i'm gon na keep you on that two . five norvasc your your blood pressures look good so i'm not gon na make any changes there and then for your diabetes we'll keep you on the five hundred of metformin and i also want to give you a referral to nutrition to a dietitian and they will be able to help you with your your diet i know you said you have a few issues so you know they can possibly write a diet for you and if you follow it you know hopefully in the future we can get you off of both of these medications and get you back to normal so how does that all sound

1,351

doctor: okay no problem

D2N049

28

[ "Chitchat" ]

[ "Null" ]

doctor: okay no problem

1,352

doctor: hey mason good to see you today so let's see you here in my notes for evaluation of kidney stones your your pcp said you had some kidney stones so you got a referral over so can you tell me a little bit about that you know what happened when did you first notice them patient: yeah it was about you know about a week ago and i was working down in the the barn with the horses and you know i was moving some hay but i developed this real sudden onset of pain in my right back and i thought it initially it was from throwing hay but it i broke out into a sweat i got real nauseated and that's when i went and saw my doctor and he ordered a cat scan and said that i had a kidney stone but you know that's i i've never had that before my father's had them in the past but yeah so that's that's how that all happened

D2N050

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

hey mason good to see you today so let's see you here in my notes for evaluation of kidney stones your your pcp said you had some kidney stones so you got a referral over so can you tell me a little bit about that you know what happened when did you first notice them

1,353

doctor: okay so you said you had the pain on the right hand side does it move anywhere or radiate patient: well when i had it it would it radiated almost down to my groin

D2N050

1

[ "Personal History" ]

[ "Subjective" ]

okay so you said you had the pain on the right hand side does it move anywhere or radiate

1,354

doctor: okay and is the pain constant or does it come and go patient: well when i you know after i found out i had a disk a kidney stone it came a couple times but it did n't last as long no i've been i've been straining my urine they told me to pee in this little cup

D2N050

3

[ "Personal History" ]

[ "Subjective" ]

okay and is the pain constant or does it come and go

1,355

doctor: mm-hmm patient: and i've been straining my urine and you know i do n't see anything in there

D2N050

4

[ "Personal History" ]

[ "Subjective" ]

mm-hmm

1,356

doctor: okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual patient: no not really not really darker

D2N050

5

[ "Vegetative History" ]

[ "Subjective" ]

okay have you noticed any blood in your urine i know you've been draining probably take a good look at it has it been darker than usual

1,357

doctor: okay so have you had kidney stones before and then you said your father had them but patient: i've never had a kidney stone my dad had them a lot but i've never had one

D2N050

6

[ "Family History" ]

[ "Subjective" ]

okay so have you had kidney stones before and then you said your father had them but

1,358

doctor: okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means patient: i have a stroke

D2N050

7

[ "Physical Examination" ]

[ "Objective" ]

okay alright so let me do a quick exam of you your vital signs look good i do n't see any fever or your blood pressure and heart rate are fine so let me do a quick physical exam let me press here on your belly so on your examination of your abdomen there is no tenderness to to pain to palpation of the abdomen there is no rebound or guarding there is cva there is tenderness on the right side so that means

1,359

doctor: can you repeat that patient: i did i have a stroke

D2N050

8

[ "Physical Examination" ]

[ "Objective" ]

can you repeat that

1,360

doctor: no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in the proximal right ureter and that's that duct that classes from your your kidney to down to your bladder there is no evidence of hydronephrosis that would mean that the stone is obstruct obstructing the ureter causing swelling in the kidney so there is there is no evidence of that so let's talk a little bit about my assessment and plan so you do have that kidney stone so right now i'm gon na recommend that we we have you push fluids just to help facilitate you urinating and passing the stone i'm gon na prescribe you some oxycodone five milligrams every six to eight hours for pain and you can continue to take tylenol between that for any breakthrough pain and you already have a strainer so that's good continue to use that and we can see continue that until the stone hasses and i'm also gon na order a bmp and your urinalysis and urine culture just to make sure that everything else is okay with you and based on urinalysis we can see if we need to prescribe you antibiotics see if you have any type of infection i do want to see you back in about one to two weeks and hopefully by that time you you passed the stone but if not we can discuss further treatment lithotripsy it's like a shock wave kinda breaks up that stone it's not it's not that invasive procedure but we can just we can discuss that if it has n't passed in that one to two weeks that sound good patient: that sounds perfect dear too

D2N050

9

[ "Follow-up", "Medication", "Radiology Examination", "Diagnostic Testing", "Reassessment" ]

[ "Objective", "Assessment", "Plan" ]

no no no no no so that means like everything is normal right but i feel like you you you have some tenderness and inflammation over your kidney so that has to be expected because you do have a kidney stone so i did review the results of your ct and it does show a stone that's measuring point five centimeters located in the proximal right ureter and that's that duct that classes from your your kidney to down to your bladder there is no evidence of hydronephrosis that would mean that the stone is obstruct obstructing the ureter causing swelling in the kidney so there is there is no evidence of that so let's talk a little bit about my assessment and plan so you do have that kidney stone so right now i'm gon na recommend that we we have you push fluids just to help facilitate you urinating and passing the stone i'm gon na prescribe you some oxycodone five milligrams every six to eight hours for pain and you can continue to take tylenol between that for any breakthrough pain and you already have a strainer so that's good continue to use that and we can see continue that until the stone hasses and i'm also gon na order a bmp and your urinalysis and urine culture just to make sure that everything else is okay with you and based on urinalysis we can see if we need to prescribe you antibiotics see if you have any type of infection i do want to see you back in about one to two weeks and hopefully by that time you you passed the stone but if not we can discuss further treatment lithotripsy it's like a shock wave kinda breaks up that stone it's not it's not that invasive procedure but we can just we can discuss that if it has n't passed in that one to two weeks that sound good

1,361

doctor: alright patient: thank you document

D2N050

10

[ "Chitchat" ]

[ "Null" ]

alright

1,362

doctor: so i will see you in a week or so and hopefully you've passed that stone and i'll send my nurse in with that prescription patient: okay thank you

D2N050

11

[ "Follow-up" ]

[ "Plan" ]

so i will see you in a week or so and hopefully you've passed that stone and i'll send my nurse in with that prescription

1,363

doctor: thanks

D2N050

12

[ "Chitchat" ]

[ "Null" ]

doctor: thanks

1,364

doctor: hi jeremy how are you patient: i'm really good thank you how are you

D2N051

0

[ "Greetings" ]

[ "Subjective" ]

hi jeremy how are you

1,365

doctor: i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks patient: yes

D2N051

1

[ "Acute Symptoms" ]

[ "Subjective" ]

i'm okay the the medical assistant told me that you had this ulcer on your foot that's been there for a couple of weeks

1,366

doctor: going away patient: yeah it's been there gosh it's like six or so weeks right now and it's and it's on my right foot and it's just yeah it's just not going away i'm not sure if it maybe even gotten a little worse from when i first noticed it

D2N051

2

[ "Acute Symptoms" ]

[ "Subjective" ]

going away

1,367

doctor: okay and how long did you say it's going on for patient: probably about

D2N051

3

[ "Acute Symptoms" ]

[ "Subjective" ]

okay and how long did you say it's going on for

1,368

doctor: six eight weeks maybe patient: okay and do you have any pain in your foot no no no pain at all okay now i know that you're a diabetic and you are on some insulin have your sugars been running okay yeah they have been running

D2N051

4

[ "Personal History" ]

[ "Subjective" ]

six eight weeks maybe

1,369

doctor: your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine patient: yes it it it definitely was higher than nine

D2N051

6

[ "Acute Symptoms" ]

[ "Subjective" ]

your sugars are running higher than normal okay do you recall what your last hemoglobin a1c was was it above nine

1,370

doctor: okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or patient: yeah i was you know i think initially i'm you know i was out in the backyard you know kind of you know doing some work and you know i know i you know i could've stepped on a nail or you know there was some other work but you know i'm always outside so i do n't know if that kind of led to anything or caused anything

D2N051

7

[ "Acute Symptoms" ]

[ "Subjective" ]

okay alright now what do you think caused this ulcer were you wearing some tight fitting shoes or did you have some trauma to your foot or

1,371

doctor: okay alright and have you had any fever or chills patient: no no no fever or chills you know i kinda you know get headaches pretty often i do n't know if that you know i do n't know if that's a stress or but you know always have like the tension headaches in the front

D2N051

8

[ "Acute Symptoms" ]

[ "Subjective" ]

okay alright and have you had any fever or chills

1,372

doctor: okay and do you have do you have neuropathy where you get like numbing and tingling in your feet patient: occasionally yeah occasionally especially when it's like colder outside

D2N051

9

[ "Acute Symptoms" ]

[ "Subjective" ]

okay and do you have do you have neuropathy where you get like numbing and tingling in your feet

1,373

doctor: mm-hmm kinda feels like it takes a little longer to patient: warm up but yeah i kinda have some sensation in in all my extremities

D2N051

10

[ "Acute Symptoms" ]

[ "Subjective" ]

mm-hmm kinda feels like it takes a little longer to

1,374

doctor: okay alright and then are you are you a smoker or did you smoke patient: i did back you know kind of years ago i did but yeah i have n't smoked anything in in good number of years

D2N051

11

[ "Drug History" ]

[ "Subjective" ]

okay alright and then are you are you a smoker or did you smoke

1,375

doctor: okay alright when did you stop smoking patient: couple years ago maybe four or so years ago

D2N051

12

[ "Drug History", "Drug History" ]

[ "Subjective" ]

okay alright when did you stop smoking

1,376

doctor: okay alright and how many packs a day would you smoke patient: gosh back then yeah was at least two

D2N051

13

[ "Drug History" ]

[ "Subjective" ]

okay alright and how many packs a day would you smoke

1,377

doctor: okay alright how many years did you smoke for like twenty patient: yeah at least twenty yeah twenty plus years

D2N051

14

[ "Drug History" ]

[ "Subjective" ]

okay alright how many years did you smoke for like twenty

1,378

doctor: okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk patient: no no no no pain you know just kind of you know it's just i know that it's there

D2N051

15

[ "Acute Symptoms" ]

[ "Subjective" ]

okay alright now any other symptoms do you have any problems when you walk down the street do you get any pain in your calves at all when you walk

1,379

doctor: okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no patient: no no you know it's you know i just kinda feel like i've been just trying to take it easy lately

D2N051

16

[ "Acute Symptoms" ]

[ "Subjective" ]

okay and you said you're active you're out in the yard and things like that do you go on long walks at all or no

1,380

doctor: mm-hmm patient: but yeah most most of the stuff i've been doing is just kind of hanging around the house

D2N051

17

[ "Acute Symptoms" ]

[ "Subjective" ]

mm-hmm

1,381

doctor: okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin patient: i am yes yeah i do the baby aspirin every day

D2N051

18

[ "Therapeutic History", "Personal History" ]

[ "Subjective" ]

okay alright so we talked a little bit about your diabetes let's talk about your heart disease now your heart disease you had a heart attack in twenty eighteen we put a stent into your right coronary artery you're still taking your medications for that you're still on your aspirin

1,382

doctor: okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything patient: okay and do you have a podiatrist for your yearly foot exams

D2N051

19

[ "Acute Symptoms" ]

[ "Subjective" ]

okay alright and any chest pain or shortness of breath or anything like that no no yeah no nothing more than yeah i would n't attribute anything

1,383

doctor: no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here patient: no

D2N051

20

[ "Physical Examination", "Acute Assessment" ]

[ "Objective", "Assessment" ]

no i i i do n't okay alright alright well let's go ahead i wan na just do a quick physical exam i'm just gon na be calling out some of my exam findings so your vital signs here in the office you do n't have any fever so that's good your blood pressure is great it's like one twenty seven over eighty and your heart rate is nice and slow in the sixties on your neck exam i do n't appreciate any jugular venous distention or any carotid bruits on your lung exam your lungs are clear to auscultation bilaterally on your heart exam you do have a two out of six systolic ejection murmur heard at the left base and on your lower extremity exam i do n't appreciate any palpable dorsalis pedis or posterior tibial pulses there is a two by three centimeter ulcerated lesion on the right lateral foot near the fifth metacarpal metatarsophalangeal joint there is no associated cellulitis does it hurt when i press here

1,384

doctor: there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help patient: any questions

D2N051

21

[ "Discussion", "Acute Assessment", "Referral", "Medication", "Other Treatments" ]

[ "Assessment", "Plan" ]

there is no pain to palpation of the right foot there is associated granulation tissue and some slight purulent discharge from the wound okay so what does all that mean that just means that you have this ulcer that's you know fairly sizable with i think we need to do some good wound care on it let's talk a little bit about my assessment and plan so you know i you have a nonhealing ulcer of your right foot so we need to do some studies on you to see if you have an adequate blood supply to heal this foot wound and since you since you probably do n't because of your diabetes you're here in a vascular surgeon's office we may have to go ahead and talk about being able to open up some of your arteries to improve the blood supply to your foot so that might mean getting a stent to one of your arteries in your legs to open up the blood supply it might mean mean that we might have to do some bypass surgery to to improve the blood supply to your foot in order to heal that that wound i do think that you'll be able to heal it i do n't think that we need to do anything drastic i want you to continue with your aspirin because that will help

1,385

doctor: yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay patient: sure

D2N051

22

[ "Diagnostic Testing", "Referral" ]

[ "Plan" ]

yeah i mean is this do we have to do any more tests or anything what are you we're gon na do an arterial ultrasound i'm going to go ahead and order an arterial ultrasound of your lower extremities to see what the blood supply is like and then i'm gon na go ahead and order a podiatry consult because i want them to see this wound and improve the wound care that you're doing and then for your next problem your diabetes i wan na go ahead and talk to your primary care physician we need to get your diabetes better controlled because that impacts your wound healing as well okay

1,386

doctor: sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay patient: okay perfect

D2N051

23

[ "Reassessment", "Follow-up", "Medication" ]

[ "Assessment", "Plan" ]

sure understood alright and for your last issue your coronary artery disease continue with your statin and i will talk to your cardiologist in case you need a procedure to see if you're cleared from a medical standpoint okay

1,387

doctor: alright patient: perfect thank you so much

D2N051

24

[ "Chitchat" ]

[ "Null" ]

alright

1,388

doctor: okay bye

D2N051

25

[ "Chitchat" ]

[ "Null" ]

doctor: okay bye

1,389

doctor: so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you patient: sure i've been having some back pain on my right side it's been lasting for about a week now

D2N052

0

[ "Personal History", "Greetings" ]

[ "Subjective" ]

so anna good to see you today so reading here in your appointment notes you were you were diagnosed with kidney stones from your your pcp and you currently have one and so they they had you come in so can you tell me what happened how's all that going for you

1,390

doctor: okay so on the right side so does that pain does it move anywhere or is it just kinda stay in that that one area patient: yeah it's moved down a little bit on to my right lower side a little bit

D2N052

2

[ "Personal History" ]

[ "Subjective" ]

okay so on the right side so does that pain does it move anywhere or is it just kinda stay in that that one area

1,391

doctor: side okay so how would you describe the pain is it constant or is does it come and go patient: it's pretty constant

D2N052

3

[ "Personal History" ]

[ "Subjective" ]

side okay so how would you describe the pain is it constant or is does it come and go

1,392

doctor: okay did you notice any pain when you're urinating i know i know you say you you saw you see blood but any pain with that patient: no no real pain when i'm when i'm peeing at all

D2N052

4

[ "Vegetative History" ]

[ "Subjective" ]

okay did you notice any pain when you're urinating i know i know you say you you saw you see blood but any pain with that

1,393

doctor: okay so have you taken anything i know have you tried like azo or any of that to patient: i took some ibuprofen that helped a little bit

D2N052

5

[ "Therapeutic History" ]

[ "Subjective" ]

okay so have you taken anything i know have you tried like azo or any of that to

1,394

doctor: alright have you noticed any nausea vomiting fever chills patient: i have n't thrown up but i felt a little bit nauseated

D2N052

7

[ "Vegetative History" ]

[ "Subjective" ]

alright have you noticed any nausea vomiting fever chills

1,395

doctor: little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but patient: yeah my my dad had kidney stones i think he has passed a couple of them i'm not quite sure

D2N052

8

[ "Family History" ]

[ "Subjective" ]

little nauseated yeah that's we expected so have you do you have a family history of kidney stones i know some people when they have them like their parents have them stuff but

1,396

doctor: alright and have you had any in the past or is this your first one patient: this is my first time i've never had this before

D2N052

9

[ "Personal History" ]

[ "Subjective" ]

alright and have you had any in the past or is this your first one

1,397

doctor: okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that patient: yeah yeah i had some pain over the weekend i saw my pediatrician this morning so they sent me over here they were concerned that i might have a kidney stone

D2N052

10

[ "Personal History" ]

[ "Subjective" ]

okay alright so we'll do we'll do an exam on you just to check you out so i guess you were in pain and stuff over the over the easter easter break there that

1,398

doctor: okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain patient: not so much but i i got to participate a little bit i opened some eggs i just did n't go run around and find them

D2N052

11

[ "Chitchat" ]

[ "Null" ]

okay so i'm guessing you did n't get to go find the eggs on the easter egg hunt because of the you were in pain

1,399