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doctor: okay well i i'm lucky enough my friends had an adult easter hag hunt for me and so i was able to find a couple eggs yesterday myself so i i'm glad you were able to get a few of them alright so let's do that that physical exam on you so your vitals look good you do n't have any fever your blood pressure heart ra...
D2N052
12
[ "Physical Examination" ]
[ "Objective" ]
okay well i i'm lucky enough my friends had an adult easter hag hunt for me and so i was able to find a couple eggs yesterday myself so i i'm glad you were able to get a few of them alright so let's do that that physical exam on you so your vitals look good you do n't have any fever your blood pressure heart rate is fi...
1,400
doctor: a little bit alright so on your exam of your abdomen there is mild pain and tenderness to palpation of the abdomen there's no rebound or guarding there is cva located near your flank tenderness on the right so that means that everything looks good but you do have what seems to be some inflammation of your kidne...
D2N052
13
[ "Physical Examination", "Discussion", "Other Treatments", "Radiology Examination", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
a little bit alright so on your exam of your abdomen there is mild pain and tenderness to palpation of the abdomen there's no rebound or guarding there is cva located near your flank tenderness on the right so that means that everything looks good but you do have what seems to be some inflammation of your kidney okay s...
1,401
doctor: okay yeah i i want you to to drink try drink as much as possible just to see if we can get you hydrated and pass the stone what i'm gon na do is i'm gon na prescribe you ibuprofen eight hundred milligrams you can take that as needed for pain i know you said you were in that much pain just in case it does start ...
D2N052
14
[ "Follow-up", "Medication", "Other Treatments", "Diagnostic Testing" ]
[ "Plan" ]
okay yeah i i want you to to drink try drink as much as possible just to see if we can get you hydrated and pass the stone what i'm gon na do is i'm gon na prescribe you ibuprofen eight hundred milligrams you can take that as needed for pain i know you said you were in that much pain just in case it does start to move ...
1,402
doctor: alright so we will see you back in a week or two and i'll have my nurse come in with that prescription and hopefully with all the treatment you'll be able to pass the stone okay alright
D2N052
15
[ "Chitchat" ]
[ "Null" ]
doctor: alright so we will see you back in a week or two and i'll have my nurse come in with that prescription and hopefully with all the treatment you'll be able to pass the stone okay alright
1,403
doctor: so barbara i i know you are here for some itchy scalp pain can you tell me a little bit about how you're doing patient: yeah it's still quite a problem you know something i've been suffering with for so long now it's still quite itchy and it's really embarrassing too because i'll have dandruff so much like all ...
D2N053
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
so barbara i i know you are here for some itchy scalp pain can you tell me a little bit about how you're doing
1,404
doctor: okay when did you first notice this patient: i wan na say it's been a while but probably worsening in the past like six months or so
D2N053
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay when did you first notice this
1,405
doctor: okay okay and have you seen ever noticed any rashes either when it first started or intermittently anywhere else patient: on my body no not really
D2N053
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay okay and have you seen ever noticed any rashes either when it first started or intermittently anywhere else
1,406
doctor: okay okay just mainly up underneath your on your scalp there uh and i can i can see that man that looks really itchy and scaly have you died your hair recently or used any other chemicals you you know like a new hair spray or gel patient: nothing new i mean i do dye my hair but i've been doing that for years no...
D2N053
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay okay just mainly up underneath your on your scalp there uh and i can i can see that man that looks really itchy and scaly have you died your hair recently or used any other chemicals you you know like a new hair spray or gel
1,407
doctor: yeah i you know it's funny you say that because i keep saying i earned this gray hair and i'm gon na keep it so yeah have you tried any over the counter treatments i know there is a lot out of there something you know like a t gel or any of those other have those helped patient: yeah i did that i did head and s...
D2N053
4
[ "Therapeutic History" ]
[ "Subjective" ]
yeah i you know it's funny you say that because i keep saying i earned this gray hair and i'm gon na keep it so yeah have you tried any over the counter treatments i know there is a lot out of there something you know like a t gel or any of those other have those helped
1,408
doctor: okay okay let's talk about some other symptoms any joint pain fever weight loss patient: not that i can recall i've been pretty good otherwise
D2N053
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay okay let's talk about some other symptoms any joint pain fever weight loss
1,409
doctor: okay good and going back you know to your grandparents has anybody else in the family had similar symptoms that you're aware of patient: no well maybe my sister
D2N053
6
[ "Family History" ]
[ "Subjective" ]
okay good and going back you know to your grandparents has anybody else in the family had similar symptoms that you're aware of
1,410
doctor: maybe your sister okay patient: yeah maybe my sister i mean i know she'll is no one has as bad as i do but she does report like just having a dry scalp
D2N053
7
[ "Family History" ]
[ "Subjective" ]
maybe your sister okay
1,411
doctor: okay okay now you know a lot of times we can see this with you know high levels of stress has there been any new mental or emotional stressors at work or at home patient: not really i mean it's basically the same things
D2N053
8
[ "Other Socials" ]
[ "Subjective" ]
okay okay now you know a lot of times we can see this with you know high levels of stress has there been any new mental or emotional stressors at work or at home
1,412
doctor: okay yeah i yeah we have a lot of that yes so let me go ahead and and look at this a little closer here the first off i wan na tell you the the vital signs that the my assistant took when you came in your blood pressure is one thirty over sixty eight your heart rate was ninety eight and your respiratory rate wa...
D2N053
9
[ "Physical Examination", "Discussion", "Follow-up", "Medication", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
okay yeah i yeah we have a lot of that yes so let me go ahead and and look at this a little closer here the first off i wan na tell you the the vital signs that the my assistant took when you came in your blood pressure is one thirty over sixty eight your heart rate was ninety eight and your respiratory rate was eighte...
1,413
doctor: yeah i want it's exactly what i want you to do i want you to use that that solution twice daily when you get that flare but then other than that just continue to use that t-gel shampoo patient: alright
D2N053
10
[ "Discussion", "Medication" ]
[ "Plan" ]
yeah i want it's exactly what i want you to do i want you to use that that solution twice daily when you get that flare but then other than that just continue to use that t-gel shampoo
1,414
doctor: okay i'm gon na have my nurse come in and get you discharged but i the we will see you again in three months or and again please if it gets worse please do n't hesitate to call me and come in sooner patient: alright perfect thank you
D2N053
11
[ "Follow-up" ]
[ "Plan" ]
okay i'm gon na have my nurse come in and get you discharged but i the we will see you again in three months or and again please if it gets worse please do n't hesitate to call me and come in sooner
1,415
doctor: thank you patient: okay bye
D2N053
12
[ "Chitchat" ]
[ "Null" ]
thank you
1,416
doctor: hey elijah how are you patient: i'm doing okay
D2N054
0
[ "Greetings" ]
[ "Subjective" ]
hey elijah how are you
1,417
doctor: so i see here that your primary care provider sent you over it looks like you were doing some yard work yesterday and dropped a landscape brick on your foot can what so what's going on with your right foot today patient: it's a little sore today but you know i hurt my foot before but this is the first time wher...
D2N054
1
[ "Acute Symptoms" ]
[ "Subjective" ]
so i see here that your primary care provider sent you over it looks like you were doing some yard work yesterday and dropped a landscape brick on your foot can what so what's going on with your right foot today
1,418
doctor: okay so you say you've injured your right foot before tell me a little bit about that injury patient: twenty years ago i broke my ankle i had to put in a cast but that seems to be okay but you know sometimes it'll give me trouble once in a while it feels a little sore it swells up at times
D2N054
2
[ "Personal History" ]
[ "Subjective" ]
okay so you say you've injured your right foot before tell me a little bit about that injury
1,419
doctor: okay alright so when you dropped that brick on your foot were you able to get up and keep working or did you have to get off your you know not stop weightbearing and and get off that foot can you tell me a little bit about after the traumatic incident patient: i you know it was a little sore i called a few name...
D2N054
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright so when you dropped that brick on your foot were you able to get up and keep working or did you have to get off your you know not stop weightbearing and and get off that foot can you tell me a little bit about after the traumatic incident
1,420
doctor: so what have you been doing for the pain since the initial insult patient: lucken it up
D2N054
5
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
so what have you been doing for the pain since the initial insult
1,421
doctor: okay have you taken any medications safe for example tylenol or ibuprofen for the pain patient: no i feel like taking the medicine
D2N054
6
[ "Therapeutic History" ]
[ "Subjective" ]
okay have you taken any medications safe for example tylenol or ibuprofen for the pain
1,422
doctor: okay and then just out of curiosity you said you were doing some landscaping have you been over to landscapes warehouse new here in town my wife and i were just over there this last weekend and picked up a whole bunch of stuff you had a chance to make it over there yet patient: no not yet i heard about it thoug...
D2N054
7
[ "Chitchat" ]
[ "Null" ]
okay and then just out of curiosity you said you were doing some landscaping have you been over to landscapes warehouse new here in town my wife and i were just over there this last weekend and picked up a whole bunch of stuff you had a chance to make it over there yet
1,423
doctor: alright that sounds good now just out of curiosity can you rate your pain for me right now zero being none ten being the worst pain you've ever been in your life patient: eleven out of ten
D2N054
8
[ "Acute Symptoms" ]
[ "Subjective" ]
alright that sounds good now just out of curiosity can you rate your pain for me right now zero being none ten being the worst pain you've ever been in your life
1,424
doctor: okay and then have you experienced any numbness or tingling of that foot since the incident patient: yeah the whole foot is numb
D2N054
9
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and then have you experienced any numbness or tingling of that foot since the incident
1,425
doctor: okay i'm gon na do a quick physical exam now your vitals look good and i would like to do a focused exam of your right foot the there is some bruising on the bottom part of your foot and on the top part as well and i do appreciate the associated swelling and i also recognize that you do have tenderness to palpa...
D2N054
11
[ "Physical Examination", "Discussion", "Follow-up", "Radiology Examination", "Acute Assessment", "Other Treatments" ]
[ "Objective", "Assessment", "Plan" ]
okay i'm gon na do a quick physical exam now your vitals look good and i would like to do a focused exam of your right foot the there is some bruising on the bottom part of your foot and on the top part as well and i do appreciate the associated swelling and i also recognize that you do have tenderness to palpation for...
1,426
doctor: you could but what we found is the best outcome is aligning those bones with plates and screws to make sure that they heal properly so you have the best outcome possible patient: so if the surgery is going to be tomorrow when am i going to get my mri
D2N054
12
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
you could but what we found is the best outcome is aligning those bones with plates and screws to make sure that they heal properly so you have the best outcome possible
1,427
doctor: so what what we will do is the good news is we have an outpatient mri facility downstairs and i'm going to send the order down and we'll get you your mri this afternoon patient: can i think about it and we have some time
D2N054
13
[ "Discussion", "Diagnostic Testing" ]
[ "Plan" ]
so what what we will do is the good news is we have an outpatient mri facility downstairs and i'm going to send the order down and we'll get you your mri this afternoon
1,428
doctor: alright thanks elijah
D2N054
15
[ "Chitchat" ]
[ "Null" ]
doctor: alright thanks elijah
1,429
doctor: karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you patient: i'm okay i guess
D2N055
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
karen nelson is a 3 -year-old female with no significant past medical history who comes in for evaluation of a new right eye twitch karen is accompanied by her father hi karen how are you
1,430
doctor: hey dad how are you doing patient: hey doc i am okay yeah karen has been having this eye twitch i noticed a couple of weeks ago when i talked to her pediatrician and they told me to come see you
D2N055
1
[ "Acute Symptoms" ]
[ "Subjective" ]
hey dad how are you doing
1,431
doctor: okay alright so karen have you felt the twitch patient: yeah well i mean i feel my face sometimes
D2N055
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright so karen have you felt the twitch
1,432
doctor: yeah and do you have any pain when it happens patient: no it it does n't really hurt but i noticed that dad looks real nervous when it happens
D2N055
3
[ "Acute Symptoms" ]
[ "Subjective" ]
yeah and do you have any pain when it happens
1,433
doctor: yeah i i i can understand that's because he loves you do you feel the urge to move your face patient: sometimes and then it moves and then i feel better
D2N055
4
[ "Acute Symptoms" ]
[ "Subjective" ]
yeah i i i can understand that's because he loves you do you feel the urge to move your face
1,434
doctor: okay okay and so so dad how often are you seeing the twitch on karen patient: i do n't know i mean it varies sometimes i see it several times an hour and there is other days we do n't see it at all until sometimes late afternoon but we definitely notice it you know everyday for the last several weeks
D2N055
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay okay and so so dad how often are you seeing the twitch on karen
1,435
doctor: okay so karen how is how is how is soccer patient: i like soccer
D2N055
6
[ "Other Socials" ]
[ "Subjective" ]
okay so karen how is how is how is soccer
1,436
doctor: does she patient: she yeah she tries to kick me and she pulls my hair and
D2N055
9
[ "Other Socials" ]
[ "Subjective" ]
does she
1,437
doctor: that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson patient: yeah and and then sometimes after soccer we we go and i get mcdugge's and it and it's it makes for a nice day with dad
D2N055
11
[ "Other Socials" ]
[ "Subjective" ]
that is n't very nice you gon na have to show her that that's not very nice you're gon na have to teach her a lesson
1,438
doctor: is that your favorite at mcdonald's in the the mcnuggates patient: not not really but they are cheap so
D2N055
12
[ "Chitchat" ]
[ "Null" ]
is that your favorite at mcdonald's in the the mcnuggates
1,439
doctor: okay alright well you you made dad happy at least right patient: yeah that's what he says because i'm expensive because i want dresses and dogs and stuff all the time
D2N055
13
[ "Chitchat" ]
[ "Null" ]
okay alright well you you made dad happy at least right
1,440
doctor: yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens patient: no i mean when it happens she...
D2N055
14
[ "Acute Symptoms" ]
[ "Subjective" ]
yeah well yeah who does n't well okay well hopefully we will get you you know squared away here so you can you know play your soccer and go shopping for dresses with dad so so dad tell me does the karen seem bothered or any other and have any other issues when this happens
1,441
doctor: okay alright has she has she otherwise been feeling okay since this started has she been acting normally patient: i i'd say she seems fine i mean she has been eating well and playing with her friends and she goes about her normal activities really
D2N055
15
[ "Personal History" ]
[ "Subjective" ]
okay alright has she has she otherwise been feeling okay since this started has she been acting normally
1,442
doctor: okay good patient: never even though anything was going on
D2N055
16
[ "Personal History" ]
[ "Subjective" ]
okay good
1,443
doctor: okay alright good so has has karen had any seizures in the past patient: no
D2N055
17
[ "Personal History" ]
[ "Subjective" ]
okay alright good so has has karen had any seizures in the past
1,444
doctor: no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching patient: well no uh it's just her face
D2N055
18
[ "Acute Symptoms" ]
[ "Subjective" ]
no okay and then so tell me when the twitch occurs do you ever notice any you know parts of her like moving or twitching
1,445
doctor: okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome patient: well no history of seizures but i i i never heard of that tourette thing
D2N055
20
[ "Family History" ]
[ "Subjective" ]
okay okay yeah that would be great to see that because i wan na see what's going on so thank you for that tell me is there any family history of seizures or like tourette's syndrome
1,446
doctor: yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger patient: really i had nobody in our family got anything like t...
D2N055
21
[ "Personal History" ]
[ "Subjective" ]
yeah so so toret is that it's a nervous system disorder that you know involves like repetitive movements or like unwanted sounds and it typically begins in childhood and i do n't know have you noticed anything like that with her when she was younger
1,447
doctor: okay now tell me have you noticed any other symptoms how about like fever or chills patient: no
D2N055
22
[ "Vegetative History" ]
[ "Subjective" ]
okay now tell me have you noticed any other symptoms how about like fever or chills
1,448
doctor: okay coughing headache patient: ma'am
D2N055
23
[ "Vegetative History" ]
[ "Subjective" ]
okay coughing headache
1,449
doctor: okay how about any problems with karen's sleep patient: nope
D2N055
24
[ "Vegetative History" ]
[ "Subjective" ]
okay how about any problems with karen's sleep
1,450
doctor: okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay patient: okay
D2N055
25
[ "Physical Examination" ]
[ "Objective" ]
okay okay good let's go ahead and do physical exam on karen here alright karen i'm just gon na take a look at you and and ask you to follow some commands okay
1,451
doctor: alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there patient: mm-hmm
D2N055
26
[ "Physical Examination" ]
[ "Objective" ]
alright can you follow my finger with your eyes good now can you do me a favor walk across the room for me great job okay now i want you to close your eyes and reach out your arms in front of you good now keep your eyes closed can you feel me touch you here how about okay how about there
1,452
doctor: does that feel the same patient: yeah
D2N055
27
[ "Physical Examination" ]
[ "Objective" ]
does that feel the same
1,453
doctor: okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator ...
D2N055
28
[ "Physical Examination" ]
[ "Objective" ]
okay alright so i'm just gon na check your reflexes okay alright now on your on the neurological exam the patient is awake alert and oriented times three speech is clear and fluent gait is steady heel toe walking is normal and the cranial nerves are intact without focal neurologic findings there is no pronator drift se...
1,454
doctor: good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school year...
D2N055
29
[ "Discussion", "Acute Assessment" ]
[ "Assessment", "Plan" ]
good alright so i'm gon na go ahead and tell you what we're gon na do so i'm gon na tell you my assessment and plan here so dad so for the first problem i do believe that karen does have a tick eye tics are very common in children and as many as you know one in five children have a tick during their school years and ti...
1,455
doctor: yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards patient: so you're not recommending any kind of treatment there is no pill or cream or nothi...
D2N055
30
[ "Discussion" ]
[ "Plan" ]
yeah i do n't think it's i do n't think so because it's it is the same part of her body that's moving every time that and she reports that it's somewhat of an there is an urge to blink her eye and some relief afterwards
1,456
doctor: not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay patient: alright alright sounds good
D2N055
31
[ "Discussion" ]
[ "Plan" ]
not at this time because she seems to be doing well overall and the tic has n't impacted her school or her activities but if it worsens then we can consider some treatment okay
1,457
doctor: alright thank you you guys have a good day patient: doctor
D2N055
32
[ "Chitchat" ]
[ "Null" ]
alright thank you you guys have a good day
1,458
doctor: bye karen
D2N055
33
[ "Chitchat" ]
[ "Null" ]
doctor: bye karen
1,459
doctor: alright thanks for coming in today i see on my chart here that you had a bunch of lower respiratory infections so first tell me how are you what's going on patient: you know i'm doing better now but you know last week i was really sick and i just have had enough like i was coughing a lot a lot of mucus even had...
D2N056
0
[ "Personal History", "Greetings" ]
[ "Subjective" ]
alright thanks for coming in today i see on my chart here that you had a bunch of lower respiratory infections so first tell me how are you what's going on
1,460
doctor: wow that is a lot so what did you do for some of those symptoms patient: you know i ended up drinking a lot of fluid and taking some robitussin and i actually got better over the weekend and now i'm feeling much better but what concerns me is that i i tend to get pneumonia a lot
D2N056
1
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
wow that is a lot so what did you do for some of those symptoms
1,461
doctor: okay so when you say a lot like how frequently does it occur patient: i would say it seem honestly it seems like it's every month or every other month especially over the past six six months that i just keep getting sick and i usually will end up having to go to my primary care doctor or patient urgent care and...
D2N056
2
[ "Personal History" ]
[ "Subjective" ]
okay so when you say a lot like how frequently does it occur
1,462
doctor: wow and how long do your symptoms normally last for patient: you know it could be as few as like a couple of days but sometimes it could go even up to a week
D2N056
3
[ "Acute Symptoms" ]
[ "Subjective" ]
wow and how long do your symptoms normally last for
1,463
doctor: mm-hmm you mentioned that you are a farmer did you do you notice that your symptoms occur while doing certain things on the farm patient: you know i was trying to think about that and i've been working on the farm for some time but the only thing i can think about is that i've been helping my brother out and i'...
D2N056
4
[ "Acute Symptoms" ]
[ "Subjective" ]
mm-hmm you mentioned that you are a farmer did you do you notice that your symptoms occur while doing certain things on the farm
1,464
doctor: alright do you wear a mask when you're unloading hay patient: no i do n't do that
D2N056
5
[ "Acute Symptoms" ]
[ "Subjective" ]
alright do you wear a mask when you're unloading hay
1,465
doctor: okay yeah so like that your brother does n't either patient: no i'm the only one who seems to be getting sick
D2N056
7
[ "Family History" ]
[ "Subjective" ]
okay yeah so like that your brother does n't either
1,466
doctor: alright so i know you said you were trying to like help out your brother like what's going on with him patient: you know we've just been getting really busy and so he has been working around doing other things so i've just been helping him just cover the extra load
D2N056
8
[ "Family History" ]
[ "Subjective" ]
alright so i know you said you were trying to like help out your brother like what's going on with him
1,467
doctor: mm-hmm okay alright do you have any other siblings patient: yeah there is actually ten of us
D2N056
9
[ "Family History" ]
[ "Subjective" ]
mm-hmm okay alright do you have any other siblings
1,468
doctor: wow okay that's that's a lot of siblings patient: yeah i'm okay
D2N056
10
[ "Chitchat" ]
[ "Null" ]
wow okay that's that's a lot of siblings
1,469
doctor: maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place patient: yeah we do n't need to hire any i mean have anyone else this is our family
D2N056
11
[ "Chitchat" ]
[ "Null" ]
maybe maybe we could we could always stick them in they could get some work done the holidays must be fun at your place
1,470
doctor: you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies patient: no no i have never had any problems with allergies
D2N056
12
[ "Personal History", "Family History" ]
[ "Subjective" ]
you're right keep it in the family okay so speaking of family do you have do you or anyone have a history of seasonal allergies
1,471
doctor: okay and do you smoke patient: i do n't smoke
D2N056
13
[ "Drug History" ]
[ "Subjective" ]
okay and do you smoke
1,472
doctor: do you live with anybody who does patient: i do not
D2N056
14
[ "Other Socials" ]
[ "Subjective" ]
do you live with anybody who does
1,473
doctor: okay alright so okay so now i i wan na go ahead and do my physical exam i'm gon na call out some of my findings just to make sure that i'm documenting everything and if you have any questions about what it is that i'm saying please feel free to ask okay patient: okay
D2N056
15
[ "Chitchat" ]
[ "Null" ]
okay alright so okay so now i i wan na go ahead and do my physical exam i'm gon na call out some of my findings just to make sure that i'm documenting everything and if you have any questions about what it is that i'm saying please feel free to ask okay
1,474
doctor: so i reviewed your vitals and you appear to be breathing a little fast your respiratory rate is twenty but but your oxygen is you're satting kind of fine at ninety nine percent on room air so i'm not too worried about that on for on your heart exam i do you have a regular rate and regular rhythm i do not apprec...
D2N056
16
[ "Physical Examination", "Discussion", "Diagnostic Testing", "Acute Assessment", "Other Treatments", "Radiology Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
so i reviewed your vitals and you appear to be breathing a little fast your respiratory rate is twenty but but your oxygen is you're satting kind of fine at ninety nine percent on room air so i'm not too worried about that on for on your heart exam i do you have a regular rate and regular rhythm i do not appreciate any...
1,475
doctor: so ideally what we are doing i think this is the best course of action to deal with the deeper problem right of these infections and to kind of like clear up the pneumonia everything seems to hint on so what we're gon na do is treat your current infection we're going to either prevent you from being around hay ...
D2N056
17
[ "Discussion", "Other Treatments" ]
[ "Plan" ]
so ideally what we are doing i think this is the best course of action to deal with the deeper problem right of these infections and to kind of like clear up the pneumonia everything seems to hint on so what we're gon na do is treat your current infection we're going to either prevent you from being around hay or make ...
1,476
doctor: alright patient: thank you
D2N056
18
[ "Chitchat" ]
[ "Null" ]
alright
1,477
doctor: okay no problem patient: alright
D2N056
19
[ "Chitchat" ]
[ "Null" ]
okay no problem
1,478
doctor: hi good afternoon joseph how are you doing today patient: i'm doing well but my my big toe hurts and it's a little red too but it really hurts okay how long has this been going on i would say you know off and on for about two weeks but last week is is when it really became painful i was at a a trade show conven...
D2N057
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hi good afternoon joseph how are you doing today
1,479
doctor: okay does it throb ache burn what kind of pain do you get with it patient: it's almost like a throbbing pain but occasionally it becomes almost like a a sharp stabbing pain especially if i move it or spend too much time walking i i find myself walking on my heel just to keep that toe from bending
D2N057
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay does it throb ache burn what kind of pain do you get with it
1,480
doctor: okay sorry i got a text and patient: well that's okay you know what i i you know i what i really you know i love to ride bikes have you you ride bike at all
D2N057
2
[ "Chitchat" ]
[ "Null" ]
okay sorry i got a text and
1,481
doctor: no i hate riding a bike i'm more of a runner patient: my gosh i love to ride i ride the lot of rails the trails i mean i go all the last year i put in over eight hundred miles on rails the trails
D2N057
3
[ "Chitchat" ]
[ "Null" ]
no i hate riding a bike i'm more of a runner
1,482
doctor: yeah those those are nice patient: yeah
D2N057
4
[ "Chitchat" ]
[ "Null" ]
yeah those those are nice
1,483
doctor: does it does riding your bike bother your big toe patient: no because i i kinda pedal with the the back of my feet you know on that side
D2N057
5
[ "Acute Symptoms" ]
[ "Subjective" ]
does it does riding your bike bother your big toe
1,484
doctor: okay do do you wear clips or are you just wearing a regular shoe and on a regular pedal patient: i'm on a regular shoe some most of the time i'm in my flip flops
D2N057
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay do do you wear clips or are you just wearing a regular shoe and on a regular pedal
1,485
doctor: okay okay the how is there anything that you were doing out of the ordinary when this started patient: no i do n't that's the thing i do n't remember an injury if it was something that i injured i think i would have just ignored it and would n't have showed up here but when it got red and warm to touch that's w...
D2N057
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay okay the how is there anything that you were doing out of the ordinary when this started
1,486
doctor: okay do does even light pressure to it bother it like at night when you're laying in bed do the sheets bother patient: absolutely i was just gon na say when i'm in bed at night and those sheets come down on it or i roll over yeah that hurts a lot
D2N057
8
[ "Acute Symptoms" ]
[ "Subjective" ]
okay do does even light pressure to it bother it like at night when you're laying in bed do the sheets bother
1,487
doctor: okay have you done anything to try to get it to feel better any soaks or taking any medicine patient: i take you know like a two ibuprofen a day and that does n't seem to help
D2N057
9
[ "Therapeutic History" ]
[ "Subjective" ]
okay have you done anything to try to get it to feel better any soaks or taking any medicine
1,488
doctor: let me see your your foot here and let me take your big toe through a range of motion if i push your top to bottom patient: yeah ouch
D2N057
11
[ "Physical Examination" ]
[ "Objective" ]
let me see your your foot here and let me take your big toe through a range of motion if i push your top to bottom
1,489
doctor: big toe joint that okay and let me move it up where as i bend it up does that hurt patient: it hurts but not as much as when you moved it down
D2N057
12
[ "Physical Examination" ]
[ "Objective" ]
big toe joint that okay and let me move it up where as i bend it up does that hurt
1,490
doctor: okay so i'm moving it down here and it i've got about ten degrees of plantar flexion does that hurt patient: yeah it a little when you take it a little further
D2N057
13
[ "Physical Examination" ]
[ "Objective" ]
okay so i'm moving it down here and it i've got about ten degrees of plantar flexion does that hurt
1,491
doctor: if i go a little bit further to twenty degrees does that hurt patient: that hurts more yeah
D2N057
14
[ "Physical Examination" ]
[ "Objective" ]
if i go a little bit further to twenty degrees does that hurt
1,492
doctor: okay if i push in on your big toe and move it back and forth does that hurt patient: yes it does and it it's almost like those joints that when you push it back it's almost like it's grinding a little bit too
D2N057
15
[ "Physical Examination" ]
[ "Objective" ]
okay if i push in on your big toe and move it back and forth does that hurt
1,493
doctor: okay if i push in between your big toe and your second toe here does that hurt patient: a little bit but not terrible
D2N057
16
[ "Physical Examination" ]
[ "Objective" ]
okay if i push in between your big toe and your second toe here does that hurt
1,494
doctor: okay what about if i push on the other side here patient: yeah yeah right there on the outside of it absolutely
D2N057
17
[ "Physical Examination" ]
[ "Objective" ]
okay what about if i push on the other side here
1,495
doctor: okay and i'm feeling a little bit of bone spur here as well let me let me get an x-ray patient: okay
D2N057
19
[ "Acute Symptoms", "Radiology Examination" ]
[ "Subjective", "Objective" ]
okay and i'm feeling a little bit of bone spur here as well let me let me get an x-ray
1,496
doctor: and after we take a peek at that we'll develop a plan patient: okay
D2N057
20
[ "Chitchat" ]
[ "Null" ]
and after we take a peek at that we'll develop a plan
1,497
doctor: so at this point what would i do if i'm going out of the room and then coming back patient: you could hit pause or hit the stop button and just restart it the next time you come in
D2N057
21
[ "Chitchat" ]
[ "Null" ]
so at this point what would i do if i'm going out of the room and then coming back
1,498
doctor: okay alrighty so taking a look at your x-ray and you do have you you have a large spur there on the top of your big toe joint patient: oh
D2N057
22
[ "Radiology Examination" ]
[ "Objective", "Assessment" ]
okay alrighty so taking a look at your x-ray and you do have you you have a large spur there on the top of your big toe joint
1,499