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doctor: okay so are you thinking of driving patient: i i think so i think i'm i think i'm gon na end up driving but that's still a a long trip
D2N062
5
[ "Other Socials" ]
[ "Subjective" ]
okay so are you thinking of driving
1,600
doctor: yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms patient: no i wish unfortunately i've gained some weight
D2N062
6
[ "Vegetative History" ]
[ "Subjective" ]
yeah absolutely i can see how that would that would increase your stress but like with that have you lost any weight because of your symptoms
1,601
doctor: okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea patient: sometime my belly hurts up here
D2N062
7
[ "Vegetative History" ]
[ "Subjective" ]
okay and do you have any other symptoms like abdominal pain nausea vomiting diarrhea
1,602
doctor: okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool patient: not that i noticed
D2N062
8
[ "Vegetative History" ]
[ "Subjective" ]
okay alright so epigastric pain alright any blood in your stool or dark dark tarry stool
1,603
doctor: okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt patient: no i did that hurts
D2N062
9
[ "Physical Examination" ]
[ "Objective" ]
okay alright so i'm gon na go ahead and do my physical exam i'll be calling up my findings as i run through it if you have any questions please let me know alright so with your vital signs your blood pressure looks pretty decent we have it like one thirty three over seventy so that's fine your heart rate looks good you do n't have a fever i do notice that in your chart it looks like you have gained you know about like ten pounds over the last month so i i do understand when you say that you've experienced some weight gain your you're satting pretty well your o2 sat is at a hundred percent so and then your breathing rate is pretty normal at nineteen so i'm gon na go ahead and do my mouth exam there are no obvious ulcers or evidence of thrush present tonsils are midline your neck i do n't appreciate any adenopathy no thyroid thyromegaly on your abdomen it is nondistended active bowel sounds so when i press here on that top part of your stomach does it hurt
1,604
doctor: okay pain to palpation of epigastric area how about now patient: no
D2N062
10
[ "Physical Examination" ]
[ "Objective" ]
okay pain to palpation of epigastric area how about now
1,605
doctor: okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for your i reviewed the results of your barium swallow and it showed that you have two areas of mild narrowing in the mid and lower portions of your esophagus that can be found in patients experiencing something called esophagitis so for your primary primary problem you have acute esophagitis i wan na go ahead and prescribe protonix it's forty milligrams you're gon na take that once a day you should take it the first thing in the morning i also wan na prescribe to you something called carafate you take one gram four times a day for one month that's just gon na help kind of coat your the in the lining of your esophagus and like your stomach so that you're again like not producing a whole lot of acid like your your pretty much your the acid in your stomach is getting where it does n't need to be and it's a bit too strong so we're gon na give your body time to do a reset i wan na schedule you for an upper endoscopy just to be sure we are n't missing anything else i encourage you to change your diet and decrease alcohol and caffeine i know that's gon na be pretty hard with the move but you know once especially once you're settled in it's gon na be very important for us to to like focus on like getting well and eating healthy so that you know like you can you can move about your day as best as you can and and enjoy your move i want you to consider like eating slowly and chewing your food more thoroughly so that you do n't have to deal with those big pieces i also want you to avoid citrus foods fruits and spicy foods until your symptoms have improved i wan na see you again next week for that endoscopy i know there was a lot of information do you have any questions patient: no i think that's all good
D2N062
11
[ "Discussion", "Follow-up", "Medication", "Other Treatments", "Radiology Examination", "Diagnostic Testing", "Acute Assessment", "Drug History" ]
[ "Objective", "Assessment", "Plan" ]
okay negative murphy's sign no peritoneal signs no rebound your on examination of the lungs they sound clear to auscultation bilaterally i do n't see any rash no lesion no bruising your eyes seem equal and reactive to light so all of these things sound pretty decent so let's talk about like the results that i got for your i reviewed the results of your barium swallow and it showed that you have two areas of mild narrowing in the mid and lower portions of your esophagus that can be found in patients experiencing something called esophagitis so for your primary primary problem you have acute esophagitis i wan na go ahead and prescribe protonix it's forty milligrams you're gon na take that once a day you should take it the first thing in the morning i also wan na prescribe to you something called carafate you take one gram four times a day for one month that's just gon na help kind of coat your the in the lining of your esophagus and like your stomach so that you're again like not producing a whole lot of acid like your your pretty much your the acid in your stomach is getting where it does n't need to be and it's a bit too strong so we're gon na give your body time to do a reset i wan na schedule you for an upper endoscopy just to be sure we are n't missing anything else i encourage you to change your diet and decrease alcohol and caffeine i know that's gon na be pretty hard with the move but you know once especially once you're settled in it's gon na be very important for us to to like focus on like getting well and eating healthy so that you know like you can you can move about your day as best as you can and and enjoy your move i want you to consider like eating slowly and chewing your food more thoroughly so that you do n't have to deal with those big pieces i also want you to avoid citrus foods fruits and spicy foods until your symptoms have improved i wan na see you again next week for that endoscopy i know there was a lot of information do you have any questions
1,606
doctor: okay alright thank you so much for coming in
D2N062
12
[ "Chitchat" ]
[ "Null" ]
doctor: okay alright thank you so much for coming in
1,607
doctor: so gloria is a 46 -year-old female today with past medical history of diabetes and back pain and today here for shortness of breath with chf and copd also so gloria tell me what's going on patient: i i i'm having a lot of trouble sleeping
D2N063
0
[ "Acute Symptoms", "Personal History", "Greetings" ]
[ "Subjective" ]
so gloria is a 46 -year-old female today with past medical history of diabetes and back pain and today here for shortness of breath with chf and copd also so gloria tell me what's going on
1,608
doctor: okay and and how long has this been going on for patient: really just for about the past two weeks i i just ca n't ca n't get comfortable you know when i when i lay down in bed i just ca n't ca n't fall
D2N063
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and and how long has this been going on for
1,609
doctor: is it because you're having you ca n't sleep or you're having shortness of breath or difficulty breathing or what's going on with that patient: yeah i i feel like i'm just i'm just choking a few minutes after i i lay down to sleep i just ca n't catch my breath
D2N063
2
[ "Acute Symptoms" ]
[ "Subjective" ]
is it because you're having you ca n't sleep or you're having shortness of breath or difficulty breathing or what's going on with that
1,610
doctor: okay and are you and how has your pulse ox been your oxygen level been at home i know you your oxygen level here is like ninety two right now in the office which is a little bit on the low side how is how has that been at home patient: i can breathe fine
D2N063
3
[ "Personal History" ]
[ "Subjective" ]
okay and are you and how has your pulse ox been your oxygen level been at home i know you your oxygen level here is like ninety two right now in the office which is a little bit on the low side how is how has that been at home
1,611
doctor: just when you lay down you get short of breath okay and is it worse when you have you noticed any shortness of breath during the day when you exert yourself when you climb stairs or do other stuff patient: i do n't i do n't do any of that usually i just i i sit on the couch and watch my shows
D2N063
4
[ "Personal History" ]
[ "Subjective" ]
just when you lay down you get short of breath okay and is it worse when you have you noticed any shortness of breath during the day when you exert yourself when you climb stairs or do other stuff
1,612
doctor: okay fair enough and how about have you noticed any weight gain or swelling in your legs or calves or anything like that patient: yeah i i ca n't see my ankles anymore and and yeah i i do n't know what's going on with the scale i think the numbers are off because you know suddenly i gained about ten pounds
D2N063
5
[ "Vegetative History" ]
[ "Subjective" ]
okay fair enough and how about have you noticed any weight gain or swelling in your legs or calves or anything like that
1,613
doctor: wow okay alright and are you taking i know you were supposed to be taking lasix and we had you on you know diet control to to prevent to limit your salt intake how is that going patient: i i i do n't know how much salt is in freedoes but you know i i i'm really enjoying those in last weekend we got this really big party and yeah which color is that lasix pill
D2N063
6
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
wow okay alright and are you taking i know you were supposed to be taking lasix and we had you on you know diet control to to prevent to limit your salt intake how is that going
1,614
doctor: yeah it's it's the white one the round one so it sounds like you're not maybe not taking it as regularly as you should patient: no sir i i do n't think i am
D2N063
7
[ "Therapeutic History" ]
[ "Subjective" ]
yeah it's it's the white one the round one so it sounds like you're not maybe not taking it as regularly as you should
1,615
doctor: okay alright and are you having any chest pain or tightness in your chest or anything like that or not really patient: no not really
D2N063
8
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright and are you having any chest pain or tightness in your chest or anything like that or not really
1,616
doctor: okay got it patient: yeah
D2N063
10
[ "Chitchat" ]
[ "Null" ]
okay got it
1,617
doctor: so i'll examine you in a second so it's been a couple of weeks are you coughing up anything any fevers with this at all patient: no no fever kinda feel like i'm just bringing a whole bunch of yuck up once in a while though especially first thing in the morning
D2N063
11
[ "Vegetative History" ]
[ "Subjective" ]
so i'll examine you in a second so it's been a couple of weeks are you coughing up anything any fevers with this at all
1,618
doctor: okay alright and how have your blood sugars been doing this time i know you're taking the metformin are you checking your accu-cheks how has that been going patient: i i'm sorry what's an accu-chek
D2N063
12
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
okay alright and how have your blood sugars been doing this time i know you're taking the metformin are you checking your accu-cheks how has that been going
1,619
doctor: for your blood sugar check are you checking that or not really patient: i i i did it a couple of weeks ago
D2N063
13
[ "Personal History" ]
[ "Subjective" ]
for your blood sugar check are you checking that or not really
1,620
doctor: okay so your hemoglobin a1c last time was seven . five and we had talked about you know trying to improve your diet we had talked about you know we wan na avoid going to insulin but it sounds like it's been a challenge to kinda control the diet and also your blood sugars have been running a little bit high patient: yeah
D2N063
15
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
okay so your hemoglobin a1c last time was seven . five and we had talked about you know trying to improve your diet we had talked about you know we wan na avoid going to insulin but it sounds like it's been a challenge to kinda control the diet and also your blood sugars have been running a little bit high
1,621
doctor: okay alright patient: yeah it's it's been a challenge
D2N063
16
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
okay alright
1,622
doctor: alright and any nausea vomiting or diarrhea or anything like that are you peeing a whole lot or anything like that no patient: yeah i'm feeling like crazy
D2N063
17
[ "Vegetative History" ]
[ "Subjective" ]
alright and any nausea vomiting or diarrhea or anything like that are you peeing a whole lot or anything like that no
1,623
doctor: okay alright patient: ca n't figure out why because i'm not drinking very much
D2N063
18
[ "Vegetative History" ]
[ "Subjective" ]
okay alright
1,624
doctor: alright and how is your back then has that been okay i know you're sitting you said you're sitting on the couch a lot watching tv but patient: yeah
D2N063
19
[ "Acute Symptoms" ]
[ "Subjective" ]
alright and how is your back then has that been okay i know you're sitting you said you're sitting on the couch a lot watching tv but
1,625
doctor: besides that anything else patient: yeah you know it it just it just really hurts so you know and so that's why i sit on the couch so much
D2N063
20
[ "Acute Symptoms" ]
[ "Subjective" ]
besides that anything else
1,626
doctor: okay alright no weakness or numbness in your legs right now patient: no
D2N063
21
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright no weakness or numbness in your legs right now
1,627
doctor: so let me examine you now gloria i'm gon na go ahead and do an exam and let's pretend i did my exam i'm just gon na verbalize some of my findings just so i can record this and put it into my my into my chart so neck exam you do have a little bit of swelling in your neck little bit of jvd no bruits your lung exam you have some crackles in both bases and some rales that i can hear and there are a little bit of intermittent wheezing as well on your heart exam you have a two over six systolic ejection murmur you've had that in the past otherwise regular rate and rhythm it does n't feel a regular your belly exam your belly's slightly distended there's no tenderness or guarding or anything like that so that does n't that looks pretty good on your leg exam you do have some one plus pitting edema or actually almost one and a half plus pitting edema in your both of your ankles no calf tenderness negative homans sign that means no blood clots otherwise neurologic exam is normal the rest of your exam is normal so what does this all mean so let me explain that so for the first problem the shortness of breath you know i think you have an exacerbation of your congestive heart failure what i'd like to do is increase your dose of lasix from twenty milligrams to sixty milligrams for the next four days i'm gon na have you check your weights everyday and also i'm gon na go ahead and have you use your albuterol and atrovent we had given you some inhalers in the past i can give you another refill if you need to help with that some of the breathing that you're having the shortness of breath so i'd like to get some of this fluid off you have you check your weights daily we'll have you increase your dose of lasix we'll have you use a breathing treatments and see if that helps your shortness of breath i'd like to have you come back in about couple days actually i wan na see how you're doing and if it does n't get better we may have to increase the dose or send you to the hospital okay patient: i do n't want to go to the hospital doctor
D2N063
23
[ "Physical Examination", "Discussion", "Follow-up", "Medication", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
so let me examine you now gloria i'm gon na go ahead and do an exam and let's pretend i did my exam i'm just gon na verbalize some of my findings just so i can record this and put it into my my into my chart so neck exam you do have a little bit of swelling in your neck little bit of jvd no bruits your lung exam you have some crackles in both bases and some rales that i can hear and there are a little bit of intermittent wheezing as well on your heart exam you have a two over six systolic ejection murmur you've had that in the past otherwise regular rate and rhythm it does n't feel a regular your belly exam your belly's slightly distended there's no tenderness or guarding or anything like that so that does n't that looks pretty good on your leg exam you do have some one plus pitting edema or actually almost one and a half plus pitting edema in your both of your ankles no calf tenderness negative homans sign that means no blood clots otherwise neurologic exam is normal the rest of your exam is normal so what does this all mean so let me explain that so for the first problem the shortness of breath you know i think you have an exacerbation of your congestive heart failure what i'd like to do is increase your dose of lasix from twenty milligrams to sixty milligrams for the next four days i'm gon na have you check your weights everyday and also i'm gon na go ahead and have you use your albuterol and atrovent we had given you some inhalers in the past i can give you another refill if you need to help with that some of the breathing that you're having the shortness of breath so i'd like to get some of this fluid off you have you check your weights daily we'll have you increase your dose of lasix we'll have you use a breathing treatments and see if that helps your shortness of breath i'd like to have you come back in about couple days actually i wan na see how you're doing and if it does n't get better we may have to increase the dose or send you to the hospital okay
1,628
doctor: yeah so let's try to let's try to use the lasix and let's try to let's try to you know use the breathing treatments and and do that for the second problem the diabetes that we just talked about i like to go ahead and order another blood test another hemoglobin a1c i think we need to your blood sugars have been running a little bit high in the past and we've had a hard time but it's been a while since we checked your last one so i wan na check another one today to see where we are and when we have you come back in a couple days we should have the results back we can then adjust your metformin or we may have to adjust some of the you know add a different medication at that point but but right now i'm gon na order some blood tests we'll have you come back in a couple of days and then we can reassess at that point okay patient: so i had a piece of cake before i came in here is that gon na affect the the lab work
D2N063
24
[ "Discussion", "Follow-up", "Medication", "Diagnostic Testing" ]
[ "Plan" ]
yeah so let's try to let's try to use the lasix and let's try to let's try to you know use the breathing treatments and and do that for the second problem the diabetes that we just talked about i like to go ahead and order another blood test another hemoglobin a1c i think we need to your blood sugars have been running a little bit high in the past and we've had a hard time but it's been a while since we checked your last one so i wan na check another one today to see where we are and when we have you come back in a couple days we should have the results back we can then adjust your metformin or we may have to adjust some of the you know add a different medication at that point but but right now i'm gon na order some blood tests we'll have you come back in a couple of days and then we can reassess at that point okay
1,629
doctor: yeah we'll probably do a fasting blood sugar we'll we'll order the hemoglobin a1c that should n't be actually matter because that checks long term but if we need your blood sugar may be elevated today i i would n't be surprised alright and i forgot to examine your back by the way so on your back exam you do have some tenderness in the paraspinal areas of your back in the in the lower back mostly no midline tenderness you have good reflexes so i think this is all muscular pain right now for your back pain i'm gon na go ahead and put you on some naprosyn and some flexeril which is a muscle relaxer i'm gon na give you some exercises you can do to help you get off the couch it'll also help your blood sugar and why do n't we have you if that does n't work the the pain medicine and the physical we can start physical therapy and see if that helps okay patient: okay
D2N063
25
[ "Discussion", "Medication", "Diagnostic Testing" ]
[ "Plan" ]
yeah we'll probably do a fasting blood sugar we'll we'll order the hemoglobin a1c that should n't be actually matter because that checks long term but if we need your blood sugar may be elevated today i i would n't be surprised alright and i forgot to examine your back by the way so on your back exam you do have some tenderness in the paraspinal areas of your back in the in the lower back mostly no midline tenderness you have good reflexes so i think this is all muscular pain right now for your back pain i'm gon na go ahead and put you on some naprosyn and some flexeril which is a muscle relaxer i'm gon na give you some exercises you can do to help you get off the couch it'll also help your blood sugar and why do n't we have you if that does n't work the the pain medicine and the physical we can start physical therapy and see if that helps okay
1,630
doctor: any questions about that patient: i do n't think so which color pills
D2N063
26
[ "Discussion" ]
[ "Plan" ]
any questions about that
1,631
doctor: i think it's a white pill and it's round patient: okay
D2N063
27
[ "Discussion" ]
[ "Plan" ]
i think it's a white pill and it's round
1,632
doctor: about this big patient: alright sounds good
D2N063
28
[ "Discussion" ]
[ "Plan" ]
about this big
1,633
doctor: anything else gloria patient: no that's it
D2N063
29
[ "Discussion" ]
[ "Plan" ]
anything else gloria
1,634
doctor: alright thanks for coming in today
D2N063
30
[ "Chitchat" ]
[ "Null" ]
doctor: alright thanks for coming in today
1,635
doctor: hey matthew how're you doing patient: hey doc i'm doing pretty good how are you
D2N064
0
[ "Greetings" ]
[ "Subjective" ]
hey matthew how're you doing
1,636
doctor: i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that patient: yeah i did my wife and i were on a walk yesterday and i was just talking to her and and stepped off the curb and landed on it wrong it's kind of embarrassing but yeah it's been killing me for a couple days now
D2N064
1
[ "Acute Symptoms" ]
[ "Subjective" ]
i'm doing pretty good hey i see here in the nurse's notes it looks like you hurt your left ankle can you tell me a little bit more about that
1,637
doctor: okay now when you fell did you feel or hear a pop or anything like that patient: i would n't say i really heard a pop it was just kind of really kind of felt extended and stretched and it it's just been really bothering me ever since kind of on the outside of it
D2N064
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay now when you fell did you feel or hear a pop or anything like that
1,638
doctor: okay and then were you able to walk on it after the incident patient: i was able to get back to the house because i did n't wan na you know make my wife carry me but it was it was painful
D2N064
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and then were you able to walk on it after the incident
1,639
doctor: okay and then have you done any or had any injuries to that ankle before patient: nothing substantial that i would say in the past
D2N064
4
[ "Personal History" ]
[ "Subjective" ]
okay and then have you done any or had any injuries to that ankle before
1,640
doctor: okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less patient: i have taken some ibuprofen and then i just tried to elevate it and ice it a little bit and keep my weight off of it
D2N064
5
[ "Therapeutic History" ]
[ "Subjective" ]
okay and then what have you been doing for that left ankle since then have you done anything to help make it make the pain less
1,641
doctor: okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me patient: i would say it's about an eight
D2N064
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay so let's talk real quick about your pain level zero being none ten being the worst pain you've been in in your life without any medication on board can you rate your pain for me
1,642
doctor: okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then patient: maybe a seven it it's a little
D2N064
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and then when you do take that ibuprofen or tylenol what what's your relief level what's your pain look like then
1,643
doctor: okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there patient: we have n't yet but i'm sure we'll check it out ever since i feel like working at home during covid we we we take walks all the time
D2N064
8
[ "Other Socials" ]
[ "Subjective" ]
okay now you mentioned going for a walk my wife and i've been on on back behind the new rex center where the new trails are have you guys been back there
1,644
doctor: yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay patient: awesome
D2N064
10
[ "Chitchat" ]
[ "Null" ]
yeah those those trails are great there's like five miles of regular flat trails and then there's a bunch of hiking trails that they've opened up as well it's a really great place man you guys need to get out there we'll get you fixed up and we'll get you back out there okay
1,645
doctor: so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up patient: no i think that sounds like a plan
D2N064
11
[ "Physical Examination", "Discussion", "Follow-up", "Medication", "Other Treatments", "Radiology Examination", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
so let's let's talk a little bit about my physical exam if it's okay with you i'm gon na do a quick physical exam on you your vitals look stable by the way a little elevated i know you're in pain on a focused exam of your left ankle now i do appreciate that there is ecchymosis or bruising over the lateral malleolus and there is some swelling i do i do appreciate some edema now you are positive for tenderness to palpation on the lateral side and the the soft tissue is swollen here the good news is i do not appreciate any laxity in the joint okay and i do n't feel any any type of bony tenderness to palpation of your foot now on the neurovascular exam of your left foot capillary refill is brisk less than three seconds and i do appreciate strong dorsalis pedis pulses and you do have motor and sensation intact which is good now it's important that they were compared bilaterally and they are yeah your your exam is the same bilaterally so that that's an important thing now we did do an x-ray of that left ankle when you came in so i'm gon na review those x-ray results with you now the good news is i do not appreciate a fracture or any bony abnormalities so that's a good thing right so let me talk to you a little bit about my assessment and plan so for your first problem of your left ankle pain your symptoms are consistent with an ankle sprain of the lateral ligament complex and the ligament on the outside of your ankle is what got stretched when you fell now the best treatment for this sprain is what you've kind of already been doing doing the elevation and compression and ice so we're gon na continue the rice protocol and i am gon na go ahead and give you an air cast just to stabilize that ankle i'm gon na prescribe you some crutches i want you to stay off that leg but i do want you to start walking as tolerated but it may be a few days before you feel like doing that now your symptoms are going to get better significantly over the first you know four five six seven days but i am gon na wan na follow up with you just to make sure you're doing okay so what i do is i would like to see you in two weeks and i'm gon na have you continue taking those nsaids as well to help reduce that pain and swelling any other questions comments or concerns before i have the nurse come in and get you fixed up
1,646
doctor: okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks patient: awesome thanks document
D2N064
12
[ "Discussion", "Follow-up" ]
[ "Plan" ]
okay sounds good like i said i will see you in two weeks if you have any questions or if you have a lot of pain come back in we'll reevaluate otherwise i think you're headed in the right direction and i'll see you again in two weeks
1,647
doctor: alright thanks bye-bye
D2N064
13
[ "Chitchat" ]
[ "Null" ]
doctor: alright thanks bye-bye
1,648
doctor: hey anna good to see you today so i'm looking here in my notes says you have you're coming in today for some right ankle pain after a fall so can you tell me what happened how did you fall patient: yeah so i was taking out the trash last night and i ended up slipping on a patch of ice like and then when i fell i heard this pop and it just hurts
D2N065
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hey anna good to see you today so i'm looking here in my notes says you have you're coming in today for some right ankle pain after a fall so can you tell me what happened how did you fall
1,649
doctor: okay so have you been able to walk on it at all or is it you know patient: at first no like my friend who was visiting thankfully had to help me get into the house and i you know and now i'm able to put like a little bit of weight on it but i'm i i'm still limping
D2N065
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay so have you been able to walk on it at all or is it you know
1,650
doctor: okay well you know that's not good we'll we'll hopefully we can get you fixed up here so how much how much pain have you been in on a scale of one to ten with ten being the worst pain you ever felt patient: it's it's more like so when i first fell it was pretty bad but now it's it's at like a six you know like it's uncomfortable
D2N065
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay well you know that's not good we'll we'll hopefully we can get you fixed up here so how much how much pain have you been in on a scale of one to ten with ten being the worst pain you ever felt
1,651
doctor: okay and how would you describe that pain is it a constant pain or is it only when you move the ankle patient: it's it's constant it's like a throbbing pain you know and like when i touch it it feels kinda warm
D2N065
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and how would you describe that pain is it a constant pain or is it only when you move the ankle
1,652
doctor: okay alright yeah but yeah i can feel it here so it does feel a little bit warm so i said you've been in a little bit of pain so have you taken anything for it patient: well like last night i iced it and i kept it elevated you know i also took some ibuprofen last night and this morning
D2N065
4
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay alright yeah but yeah i can feel it here so it does feel a little bit warm so i said you've been in a little bit of pain so have you taken anything for it
1,653
doctor: alright has the ibuprofen helped at all patient: not really
D2N065
5
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
alright has the ibuprofen helped at all
1,654
doctor: okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before patient: so you know in high school i used to play a lot of soccer but and and like i had other injuries but i've never injured like this particular ankle before but because i used to play like all the time i knew what i was supposed to do but this is i also knew that it was it was time to come in
D2N065
6
[ "Personal History" ]
[ "Subjective" ]
okay alright so i just want to know i know some of my patients they have like bad ankles where they hurt the ankles all the time but have you ever injured this ankle before
1,655
doctor: okay yeah yeah definitely if you if you ca n't walk on it we definitely good thing that you came in today and we were able to see you so have you experienced any numbness in your foot at all patient: no no numbness and i do n't think i've had like any tingling or anything like that
D2N065
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay yeah yeah definitely if you if you ca n't walk on it we definitely good thing that you came in today and we were able to see you so have you experienced any numbness in your foot at all
1,656
doctor: okay that that's good yeah it sounds like you have sensation there so yeah that that's really good so let me do a quick physical exam on you so i reviewed your vitals your blood pressure was one twenty over eighty which is good your heart rate your spo2 was ninety eight percent which is good that means you're you're getting all of your oxygen and so let me go ahead and look at your ankle real quick so when i press here does that hurt patient: yeah
D2N065
8
[ "Physical Examination" ]
[ "Objective" ]
okay that that's good yeah it sounds like you have sensation there so yeah that that's really good so let me do a quick physical exam on you so i reviewed your vitals your blood pressure was one twenty over eighty which is good your heart rate your spo2 was ninety eight percent which is good that means you're you're getting all of your oxygen and so let me go ahead and look at your ankle real quick so when i press here does that hurt
1,657
doctor: alright what about here patient: yeah
D2N065
9
[ "Physical Examination" ]
[ "Objective" ]
alright what about here
1,658
doctor: okay so looking at your ankle and your right ankle exam on the skin there is ecchymosis so you have that bruising which you can see of the lateral patient: malleolus
D2N065
10
[ "Physical Examination" ]
[ "Objective" ]
okay so looking at your ankle and your right ankle exam on the skin there is ecchymosis so you have that bruising which you can see of the lateral
1,659
doctor: malleolus associated with swelling there is tenderness to palpation of the anterior laterally in the soft tissue there is no laxity on the anterior drawer and inversion stress there is no bony tenderness on palpation of the foot on your neurovascular exam of your right foot there your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch alright so we did get an x-ray of your ankle before you came in and luckily it's there is no fractures no bony abnormalities which is really good so let me talk a little bit about my assessment and plan for you so for your right ankle pain your symptoms your symptoms are consistent with a right ankle sprain have you sprained your ankle before most times people do the athletics play soccer it happens every so often but have you done that before patient: no i do n't think so
D2N065
11
[ "Physical Examination", "Personal History", "Radiology Examination", "Acute Assessment" ]
[ "Subjective", "Objective", "Assessment" ]
malleolus associated with swelling there is tenderness to palpation of the anterior laterally in the soft tissue there is no laxity on the anterior drawer and inversion stress there is no bony tenderness on palpation of the foot on your neurovascular exam of your right foot there your capillary refill is less than three seconds strong dorsalis pedis pulse and your sensation is intact to light touch alright so we did get an x-ray of your ankle before you came in and luckily it's there is no fractures no bony abnormalities which is really good so let me talk a little bit about my assessment and plan for you so for your right ankle pain your symptoms your symptoms are consistent with a right ankle sprain have you sprained your ankle before most times people do the athletics play soccer it happens every so often but have you done that before
1,660
doctor: okay well you're one of the lucky ones some of my my patients that play sports they sprain their ankle seems like every other week so good for you so for that that that ankle sprain i just want to keep i want you to keep your leg elevated when you're seated and i want you to continue to ice it you can ice it let's say five times a day for twenty minutes at a time just to help that swelling go down i'm gon na give you an air cast to help you stabilize the ankle so keep it from moving and then i'll give you crutches and so i want you to stay off that leg for about one to two days and then you can start walking on it as tolerated tolerated so how does that sound patient: it's alright
D2N065
12
[ "Discussion", "Medication", "Other Treatments" ]
[ "Plan" ]
okay well you're one of the lucky ones some of my my patients that play sports they sprain their ankle seems like every other week so good for you so for that that that ankle sprain i just want to keep i want you to keep your leg elevated when you're seated and i want you to continue to ice it you can ice it let's say five times a day for twenty minutes at a time just to help that swelling go down i'm gon na give you an air cast to help you stabilize the ankle so keep it from moving and then i'll give you crutches and so i want you to stay off that leg for about one to two days and then you can start walking on it as tolerated tolerated so how does that sound
1,661
doctor: alright so do you have any questions for me patient: yeah like how long do you think it's gon na take for me to heal
D2N065
13
[ "Discussion" ]
[ "Plan" ]
alright so do you have any questions for me
1,662
doctor: i mean it should take a a couple of days i mean i think in a day or two you will be able to walk on it but still think it will be sore for the next couple of weeks you know your ankle sprain seems to be not the worst but it's kinda you know medium grade ankle sprain so as i would say about two to three weeks you should be back to normal you will see some of that bruising go away patient: yeah okay can i get a doctor's note
D2N065
14
[ "Discussion", "Reassessment" ]
[ "Assessment", "Plan" ]
i mean it should take a a couple of days i mean i think in a day or two you will be able to walk on it but still think it will be sore for the next couple of weeks you know your ankle sprain seems to be not the worst but it's kinda you know medium grade ankle sprain so as i would say about two to three weeks you should be back to normal you will see some of that bruising go away
1,663
doctor: no because you need to go back to work because you work on the computer not running so patient: fine
D2N065
15
[ "Discussion" ]
[ "Plan" ]
no because you need to go back to work because you work on the computer not running so
1,664
doctor: yeah you ca n't get a doctor's note so if you if i write a note i'm gon na tell your boss that you have to go to work patient: okay thanks
D2N065
16
[ "Discussion" ]
[ "Plan" ]
yeah you ca n't get a doctor's note so if you if i write a note i'm gon na tell your boss that you have to go to work
1,665
doctor: so i i would n't do that but yeah but otherwise if if if you continue to have pain after this week if you feel like it's not getting better please feel free to contact the office and we can get you back in and possibly do an mri if we you know need to patient: okay
D2N065
17
[ "Discussion" ]
[ "Plan" ]
so i i would n't do that but yeah but otherwise if if if you continue to have pain after this week if you feel like it's not getting better please feel free to contact the office and we can get you back in and possibly do an mri if we you know need to
1,666
doctor: alright patient: alright
D2N065
18
[ "Chitchat" ]
[ "Null" ]
alright
1,667
doctor: anything else patient: no that's it
D2N065
19
[ "Discussion" ]
[ "Plan" ]
anything else
1,668
doctor: alright thanks
D2N065
20
[ "Chitchat" ]
[ "Null" ]
doctor: alright thanks
1,669
doctor: hey gabriel i'm doctor scott good to see you today i know you've heard about dax is it okay if i tell dax a little bit about you patient: sure
D2N066
0
[ "Greetings" ]
[ "Subjective" ]
hey gabriel i'm doctor scott good to see you today i know you've heard about dax is it okay if i tell dax a little bit about you
1,670
doctor: okay so gabriel is a 43 -year-old male today here for back pain evaluation and also has a past medical history of diabetes high blood pressure and high cholesterol so gabriel tell me what's going on with your back patient: well i was working in the yard and you know bent over to pick something up and i got this pain and you know across the lower part of my back and then it went down my left leg and you know it's been going on for about four days and just does n't seem to be getting any better
D2N066
1
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
okay so gabriel is a 43 -year-old male today here for back pain evaluation and also has a past medical history of diabetes high blood pressure and high cholesterol so gabriel tell me what's going on with your back
1,671
doctor: okay are you a big gardener or this is something that you just started working in the yard patient: yeah i know my wife held a gun to my head make me go out there work in the yard and carry some stuff around it's not my not my first choice but
D2N066
2
[ "Other Socials" ]
[ "Subjective" ]
okay are you a big gardener or this is something that you just started working in the yard
1,672
doctor: sure sure patient: but that day i i lost the i lost the argument
D2N066
3
[ "Other Socials" ]
[ "Subjective" ]
sure sure
1,673
doctor: yeah yeah that happens to all of this so when this back pain happened so it was basically you were lifting you were bending down to lift something up and you had the sharp pain going down your right leg you said patient: left leg
D2N066
4
[ "Acute Symptoms" ]
[ "Subjective" ]
yeah yeah that happens to all of this so when this back pain happened so it was basically you were lifting you were bending down to lift something up and you had the sharp pain going down your right leg you said
1,674
doctor: left leg okay got it sorry and any weakness or numbness in your legs or just the pain mostly patient: in in certain positions i get some tingling but no mostly just pain
D2N066
5
[ "Acute Symptoms" ]
[ "Subjective" ]
left leg okay got it sorry and any weakness or numbness in your legs or just the pain mostly
1,675
doctor: okay and any loss of bowel or bladder function at all or anything like that patient: no
D2N066
6
[ "Vegetative History" ]
[ "Subjective" ]
okay and any loss of bowel or bladder function at all or anything like that
1,676
doctor: okay and have you had any back surgeries or back problems in the past or this is kind of the first time patient: no surgeries you know i've i've had back pain occasionally over the years
D2N066
7
[ "Personal History" ]
[ "Subjective" ]
okay and have you had any back surgeries or back problems in the past or this is kind of the first time
1,677
doctor: okay have you had any any have you tried anything for pain for this have you tried any any medications at all patient: i've had ibuprofen it it helped some
D2N066
8
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay have you had any any have you tried anything for pain for this have you tried any any medications at all
1,678
doctor: okay got it alright well i'll i'll examine you in a second but before we do that let's talk about some of the other conditions that we're kinda following you for i'm looking at your problem list now and you've got a history of diabetes and you're on metformin five hundred milligram twice a day and your how are you doing with your blood sugars and your and your diet and exercise patient: yeah i i check my sugar two or three times a week most of the time it's in that one twenty to one forty range
D2N066
9
[ "Personal History" ]
[ "Subjective" ]
okay got it alright well i'll i'll examine you in a second but before we do that let's talk about some of the other conditions that we're kinda following you for i'm looking at your problem list now and you've got a history of diabetes and you're on metformin five hundred milligram twice a day and your how are you doing with your blood sugars and your and your diet and exercise
1,679
doctor: okay we checked your hemoglobin a1c last time i'm looking at your records in epic and it showed that it was you know seven . one so it's it's it's good but it could be better any you know we talked about it controlling your diet or improving your diet and trying to have a balanced meal and not eating some of these sweets and high sugar items how is that going i know you had talked about your wife being a great cook and making cookies and that's hard to stay away from obviously how are things going with that patient: yeah she still makes cookies and i still eat them but you know we are trying to trying to do better trying to stay away from more of those carbs and focus on you know less carby less sweet stuff
D2N066
12
[ "Personal History" ]
[ "Subjective" ]
okay we checked your hemoglobin a1c last time i'm looking at your records in epic and it showed that it was you know seven . one so it's it's it's good but it could be better any you know we talked about it controlling your diet or improving your diet and trying to have a balanced meal and not eating some of these sweets and high sugar items how is that going i know you had talked about your wife being a great cook and making cookies and that's hard to stay away from obviously how are things going with that
1,680
doctor: okay alright yeah that's always a struggle i certainly understand but you know really important with your diabetes just to prevent some of the complications like kidney failure and eye problems and just keep your sugar under balance so i'll order another hemoglobin a1c today we'll check that again today and and you know just reemphasizing the controlling your diet and exercise is super important and then we'll have those results back we'll we'll see if we need to make any modifications okay patient: okay
D2N066
13
[ "Other Treatments", "Diagnostic Testing" ]
[ "Plan" ]
okay alright yeah that's always a struggle i certainly understand but you know really important with your diabetes just to prevent some of the complications like kidney failure and eye problems and just keep your sugar under balance so i'll order another hemoglobin a1c today we'll check that again today and and you know just reemphasizing the controlling your diet and exercise is super important and then we'll have those results back we'll we'll see if we need to make any modifications okay
1,681
doctor: for your high blood pressure your blood pressure in the clinic looks pretty good it's about one twenty over seventy right now we have you on norvasc five milligrams once a day how are things going with that are you are you checking that periodically or any issues with that at all patient: yeah i guess i check it maybe once a week or two or three times a month and it it the vast majority of the time when i check it it's good usually either that one twenty to one thirty over seventy to eighty range i i think the blood pressure's okay
D2N066
14
[ "Personal History" ]
[ "Subjective" ]
for your high blood pressure your blood pressure in the clinic looks pretty good it's about one twenty over seventy right now we have you on norvasc five milligrams once a day how are things going with that are you are you checking that periodically or any issues with that at all
1,682
doctor: okay is that new or is that been going on for a while patient: well it it started maybe i do n't know a month or two after i started the norvasc
D2N066
16
[ "Personal History" ]
[ "Subjective" ]
okay is that new or is that been going on for a while
1,683
doctor: yeah i mean certainly it could be it is you know sometimes that medication can cause that so i'll i'll examine you in a second and see if we need to make any modifications okay patient: okay
D2N066
18
[ "Personal History" ]
[ "Subjective" ]
yeah i mean certainly it could be it is you know sometimes that medication can cause that so i'll i'll examine you in a second and see if we need to make any modifications okay
1,684
doctor: alright so and your anything else bothering you today patient: no i'm we're doing okay i think
D2N066
19
[ "Acute Symptoms" ]
[ "Subjective" ]
alright so and your anything else bothering you today
1,685
doctor: so let me examine you for a second i'm gon na go ahead and gabriel i'm gon na do my magic exam now let's pretend i i'm just gon na verbalize some of my findings as i do my exam and so patient: these are like my video visit exams
D2N066
20
[ "Physical Examination" ]
[ "Objective" ]
so let me examine you for a second i'm gon na go ahead and gabriel i'm gon na do my magic exam now let's pretend i i'm just gon na verbalize some of my findings as i do my exam and so
1,686
doctor: exactly so your neck exam has no jvd there is no bruits that i can hear your lung exam no rales no wheezing on your heart exam you do have a two over six systolic ejection murmur you had that in the past so i'm not too worried about that otherwise regular rate and rhythm on your heart exam on your on your on your belly exam is nice and soft on your back exam you do have some tenderness on the left paraspinal area right where i'm pressing right there your straight leg raise test is negative your reflexes are normal you have some just some tenderness in the lower back in the paraspinal area of your back when i palpate there otherwise your neurological exam is normal on your extremity exam you do have this one plus nonpitting edema of your lower extremities which is a little bit of swelling in your ankles no calf tenderness negative homans sign no signs of blood clot that's what that means so let me just review what you know explain what all this means so the back pain the first problem that you're here today for i think this is more of a muscular sprain i'm gon na recommend we start you on some anti-inflammatory naprosyn five hundred five hundred milligrams twice a day and flexeril ten milligrams twice a day as well i'm gon na refer you to for for physical therapy to help strengthen some of the muscles in your lower back i do n't think you need an x-ray at this stage why do n't we start with physical therapy and the muscle relaxers and the pain medicines if it does n't get better then we can get an x-ray but right now i would start with that if that's okay with you any questions about that patient: no
D2N066
21
[ "Physical Examination", "Discussion", "Medication", "Referral", "Diagnostic Testing", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
exactly so your neck exam has no jvd there is no bruits that i can hear your lung exam no rales no wheezing on your heart exam you do have a two over six systolic ejection murmur you had that in the past so i'm not too worried about that otherwise regular rate and rhythm on your heart exam on your on your on your belly exam is nice and soft on your back exam you do have some tenderness on the left paraspinal area right where i'm pressing right there your straight leg raise test is negative your reflexes are normal you have some just some tenderness in the lower back in the paraspinal area of your back when i palpate there otherwise your neurological exam is normal on your extremity exam you do have this one plus nonpitting edema of your lower extremities which is a little bit of swelling in your ankles no calf tenderness negative homans sign no signs of blood clot that's what that means so let me just review what you know explain what all this means so the back pain the first problem that you're here today for i think this is more of a muscular sprain i'm gon na recommend we start you on some anti-inflammatory naprosyn five hundred five hundred milligrams twice a day and flexeril ten milligrams twice a day as well i'm gon na refer you to for for physical therapy to help strengthen some of the muscles in your lower back i do n't think you need an x-ray at this stage why do n't we start with physical therapy and the muscle relaxers and the pain medicines if it does n't get better then we can get an x-ray but right now i would start with that if that's okay with you any questions about that
1,687
doctor: okay for the diabetes the the second problem that we talked about today i'm gon na order another hemoglobin a1c continue the metformin five hundred milligrams twice a day why do n't we have you come back in about two weeks and we should have some of the results back and we can discuss if we need to make any modifications for that but right now we will continue the course and we will go from there okay for the high blood pressure you do have this one plus edema in your legs i'm gon na go ahead and order some blood work today i'm gon na go ahead and stop the norvasc and we'll put you on some hydrochlorothiazide ten milligrams once a day and if that does n't get if the swelling does n't go away i'm gon na do some more testing for right now let's get some sort off with some cbc and a bmp i'm gon na check your kidney function i'm gon na get another ekg and also i'm gon na get a chest x-ray and we'll go from there but hopefully this will go away once we stop this medication since it started around that time okay okay and i think that's it anything else we forgot about do you need refills for anything patient: no i i think i'm okay you gave me a year's worth of refills last time we were together
D2N066
22
[ "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
okay for the diabetes the the second problem that we talked about today i'm gon na order another hemoglobin a1c continue the metformin five hundred milligrams twice a day why do n't we have you come back in about two weeks and we should have some of the results back and we can discuss if we need to make any modifications for that but right now we will continue the course and we will go from there okay for the high blood pressure you do have this one plus edema in your legs i'm gon na go ahead and order some blood work today i'm gon na go ahead and stop the norvasc and we'll put you on some hydrochlorothiazide ten milligrams once a day and if that does n't get if the swelling does n't go away i'm gon na do some more testing for right now let's get some sort off with some cbc and a bmp i'm gon na check your kidney function i'm gon na get another ekg and also i'm gon na get a chest x-ray and we'll go from there but hopefully this will go away once we stop this medication since it started around that time okay okay and i think that's it anything else we forgot about do you need refills for anything
1,688
doctor: okay sounds great alright thanks gabriel good seeing you again patient: good to see you thanks
D2N066
23
[ "Chitchat" ]
[ "Null" ]
okay sounds great alright thanks gabriel good seeing you again
1,689
doctor: hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee patient: yes i hurt my knee when i was skiing two weeks ago
D2N067
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hi elizabeth so i see that you were experiencing some kind of injury did you say that you hurt your knee
1,690
doctor: okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury patient: so i was flying down this black diamond you know like i like to do
D2N067
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay skiing that sounds exciting alright so what happened what what's when did the injury like what sorry what happened in the injury
1,691
doctor: so we were downhill skiing racing at this point okay is it your left or your right knee patient: it's my right
D2N067
3
[ "Acute Symptoms" ]
[ "Subjective" ]
so we were downhill skiing racing at this point okay is it your left or your right knee
1,692
doctor: okay and does it hurt on the inside or the outside patient: the inside
D2N067
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and does it hurt on the inside or the outside
1,693
doctor: okay so the medial aspect of the right knee when you fell did you hear a pop patient: i did yes
D2N067
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay so the medial aspect of the right knee when you fell did you hear a pop
1,694
doctor: okay alright patient: i think that was my left knee
D2N067
6
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright
1,695
doctor: okay okay alright so we got we got ta pick one if it if it patient: i'm just trying to be real
D2N067
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay okay alright so we got we got ta pick one if it if it
1,696
doctor: a hundred percent so how about this right now you're like i what i'm hearing is that you're experiencing bilateral knee pain like both of your knees hurt but i'm assuming that like your right knee hurts more is that correct patient: yeah my left knee does n't really hurt
D2N067
9
[ "Acute Symptoms" ]
[ "Subjective" ]
a hundred percent so how about this right now you're like i what i'm hearing is that you're experiencing bilateral knee pain like both of your knees hurt but i'm assuming that like your right knee hurts more is that correct
1,697
doctor: gotcha gotcha okay yeah i think hmmm alright so we're gon na we're gon na go ahead and look at this sort of but on a scale of one to ten how severe is your pain patient: it's a seven
D2N067
11
[ "Acute Symptoms" ]
[ "Subjective" ]
gotcha gotcha okay yeah i think hmmm alright so we're gon na we're gon na go ahead and look at this sort of but on a scale of one to ten how severe is your pain
1,698
doctor: okay that's pretty bad alright and does it has it been increasing or like rapidly or slowly over the last few days patient: it's been slow
D2N067
12
[ "Acute Symptoms" ]
[ "Subjective" ]
okay that's pretty bad alright and does it has it been increasing or like rapidly or slowly over the last few days
1,699