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|---|---|---|---|---|---|---|
doctor: okay , well i'm glad to hear that . um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ... patient: yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on... | D2N070 | 12 | [
"Personal History"
] | [
"Subjective"
] | okay , well i'm glad to hear that . um ... so let's talk a little bit about your diabetes . how are you doing with that ? i know that- you know , i remember you have a sweet tooth . so ... | 1,800 |
doctor: okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ? patient: i'm good about it during the week while i am at home working, but on the weekends when i'm out of the house i tend to forget . uh , and so it's not as regimented , ... | D2N070 | 13 | [
"Personal History"
] | [
"Subjective"
] | okay , all right . and how about your high blood pressure ? are you monitoring your blood pressure readings at home , like i recommended ? | 1,801 |
doctor: okay , and you're you're taking your medication ? patient: yes , i am . | D2N070 | 14 | [
"Therapeutic History",
"Personal History"
] | [
"Subjective"
] | okay , and you're you're taking your medication ? | 1,802 |
doctor: okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ? patient: uh ... it gets aggravated every once in a while . if i- maybe if i run too much or if i've lift boxes that are a little too heavy , i start to feel the strain . but it's been okay . n... | D2N070 | 15 | [
"Personal History"
] | [
"Subjective"
] | okay . and then lastly , i know that you had had some early arthritis in your knee . how- how are you doing with that ? | 1,803 |
doctor: okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain . have you had any other symptoms , chest pain , nausea or vomiting- patient: no . | D2N070 | 16 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | okay . all right , well ... let me go ahead and- you know , i know that the nurse did a review of systems sheet with you when you- when you checked in . i know that you were endorsing the back pain . have you had any other symptoms , chest pain , nausea or vomiting- | 1,804 |
doctor: . fever , chills ? patient: no . no none whatsoever . | D2N070 | 17 | [
"Vegetative History"
] | [
"Subjective"
] | . fever , chills ? | 1,805 |
doctor: no . okay . all right , well let me go ahead , i want to do a quick physical exam . patient: mm-hmm . | D2N070 | 18 | [
"Physical Examination"
] | [
"Objective"
] | no . okay . all right , well let me go ahead , i want to do a quick physical exam . | 1,806 |
doctor: hey dragon ? show me the blood pressure . so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your- patient: mm-hmm . | D2N070 | 19 | [
"Physical Examination"
] | [
"Objective"
] | hey dragon ? show me the blood pressure . so it's a little elevated . your blood pressure's a little elevated here in the office , but you know you could be in some pain , which could make your- | 1,807 |
doctor: . blood pressure go up . let's look at the readings . hey dragon ? show me the blood pressure readings . yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well . patient: mm-hmm . | D2N070 | 20 | [
"Physical Examination"
] | [
"Objective"
] | . blood pressure go up . let's look at the readings . hey dragon ? show me the blood pressure readings . yeah ... yeah you know they do run a little bit on the high side , so we'll have to address that as well . | 1,808 |
doctor: okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ? patient: sure . | D2N070 | 21 | [
"Physical Examination"
] | [
"Objective"
] | okay , well . let me- i'm just going to be listening your heart and your lungs and i'll check out your back and i'll let you know what i find , okay ? | 1,809 |
doctor: and kick against my hands . okay , good . all right . okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur . patient: mm-hmm . | D2N070 | 22 | [
"Physical Examination"
] | [
"Objective"
] | and kick against my hands . okay , good . all right . okay , so ... on physical examination , you know , i-i do hear a slight 2 out of 6 s- s- systolic heart murmur . | 1,810 |
doctor: on your heart exam . which you've had in the past . patient: mm-hmm . | D2N070 | 23 | [
"Physical Examination"
] | [
"Objective"
] | on your heart exam . which you've had in the past . | 1,811 |
doctor: so that sounds stable to me . on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? pati... | D2N070 | 24 | [
"Physical Examination"
] | [
"Objective"
] | so that sounds stable to me . on your back exam , you know , you do have some pain to palpation of the lumbar spine . and you have pain with flexion and extension of the back . and you have a negative straight leg raise , which is which is good . so , let's- let's just look at some of your results , okay ? | 1,812 |
doctor: hey dragon ? show me the diabetes labs . okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? patient: sure . | D2N070 | 25 | [
"Lab Examination"
] | [
"Objective"
] | hey dragon ? show me the diabetes labs . okay , so ... in reviewing the results of your diabetes labs , your hemoglobin a1c is a little elevated at eight . i'd like to see it a little bit better , okay ? | 1,813 |
doctor: hey dragon ? show me the back x-ray . so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- patient: mm-hmm . | D2N070 | 26 | [
"Radiology Examination"
] | [
"Objective"
] | hey dragon ? show me the back x-ray . so in reviewing the results of your back x-ray , this looks like a normal x-ray . there's good bony alignment , there's normal uh- there's no fracture present . uh , so this is a normal x-ray of your back , which is not surprising based on- | 1,814 |
doctor: . the history , okay ? patient: mm-hmm . | D2N070 | 27 | [
"Chitchat"
] | [
"Null"
] | . the history , okay ? | 1,815 |
doctor: so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . patient: mm-hmm . | D2N070 | 28 | [
"Acute Assessment",
"Medication"
] | [
"Assessment",
"Plan"
] | so let's just go ahead and we'll- we're going to go over , you know , my assessment and my plan for you . so for your first problem , your back pain . you know , i think you have a lumbar strain from the lifting . so , let's go ahead . we can prescribe you some meloxicam 15 mg once a day . | 1,816 |
doctor: i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- patient: mm-hmm . | D2N070 | 29 | [
"Referral",
"Medication"
] | [
"Plan"
] | i want you to continue to ice it , okay . i want you to try to avoid any strenuous activity and we can go ahead and- and refer you to physical therapy- | 1,817 |
doctor: . and see how you do , okay ? patient: you got it . | D2N070 | 30 | [
"Chitchat"
] | [
"Null"
] | . and see how you do , okay ? | 1,818 |
doctor: for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ? patient: mm-hmm . | D2N070 | 31 | [
"Reassessment",
"Diagnostic Testing",
"Medication"
] | [
"Assessment",
"Plan"
] | for your next problem , your diabetes . y-you know , i think it's a little under- out of control . so i want to increase the metformin to 1000 mg twice a day . and i'm going to um ... um ... i'm going to repeat a hemoglobin a1c in about 6 months , okay ? | 1,819 |
doctor: hey dragon ? order a hemoglobin a1c . so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day . patient: mm-hmm . | D2N070 | 32 | [
"Reassessment",
"Diagnostic Testing",
"Medication"
] | [
"Assessment",
"Plan"
] | hey dragon ? order a hemoglobin a1c . so , for your third problem , your hypertension . uh ... i-i'd like to go ahead increase the lisinopril from 10 mg to 20 mg a day . | 1,820 |
doctor: does that sound okay ? i think we need to get it under better control . patient: no that's fine . i agree . | D2N070 | 33 | [
"Discussion"
] | [
"Plan"
] | does that sound okay ? i think we need to get it under better control . | 1,821 |
doctor: hey dragon ? order lisinopril 20 mg daily . and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ... patient: mm-hmm . | D2N070 | 34 | [
"Reassessment",
"Medication"
] | [
"Assessment",
"Plan"
] | hey dragon ? order lisinopril 20 mg daily . and for your last problem , your osteoarthritis , i-i think that you were doing a really good job , in terms of you know what , monitoring your knee and uh ... | 1,822 |
doctor: i do n't think we need to do any- any further , you know , work up of that at this time , okay ? patient: mm-hmm . | D2N070 | 35 | [
"Discussion"
] | [
"Plan"
] | i do n't think we need to do any- any further , you know , work up of that at this time , okay ? | 1,823 |
doctor: do you have any questions logan ? patient: not at this point . | D2N070 | 36 | [
"Discussion"
] | [
"Plan"
] | do you have any questions logan ? | 1,824 |
doctor: okay . all right . so the nurse will come in to help you get checked out , okay ? patient: you got it . | D2N070 | 37 | [
"Chitchat"
] | [
"Null"
] | okay . all right . so the nurse will come in to help you get checked out , okay ? | 1,825 |
doctor: hey dragon ? finalize the note . | D2N070 | 38 | [
"Chitchat"
] | [
"Null"
] | doctor: hey dragon ? finalize the note . | 1,826 |
doctor: i know the nurse told you about dax . patient: mm-hmm | D2N071 | 0 | [
"Chitchat"
] | [
"Null"
] | i know the nurse told you about dax . | 1,827 |
doctor: i'd like to tell dax a little bit about you , okay ? patient: sure . | D2N071 | 1 | [
"Chitchat"
] | [
"Null"
] | i'd like to tell dax a little bit about you , okay ? | 1,828 |
doctor: so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ? patient: um , relatively speaking , okay . it was kind of a , a tough spring... | D2N071 | 2 | [
"Acute Symptoms",
"Personal History"
] | [
"Subjective"
] | so ralph is a 62-year-old male with a past medical history significant for depression and prior lobectomy as well as hypertension , who presents for his annual exam . so , ralph , it's been a while since i saw you . how are you doing ? | 1,829 |
doctor: okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing . patient: yeah . | D2N071 | 3 | [
"Chitchat"
] | [
"Null"
] | okay . i know . i know . that's a , that's a hard thing to get over , moving kids out of the house and that type of thing . | 1,830 |
doctor: so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year . patient: yeah , i've been staying on top of the meds , and i have n't had any incidents in a while , so it's , it's been pretty go... | D2N071 | 4 | [
"Personal History"
] | [
"Subjective"
] | so , um well , how are you doing from , you know , let's talk a little bit about your depression . how are you doing with that ? i know that we had put you on the prozac last year . | 1,831 |
doctor: okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ... patient: i ... i'm pretty regular with the medications during the business week , but on there's weekends , you know , if i'm on the fly or doing something , sometimes i forget , or i forget ... | D2N071 | 5 | [
"Therapeutic History"
] | [
"Subjective"
] | okay . yeah , i , i see that we have you on the norvasc . and so are you taking it at home ? is it running high , or ... | 1,832 |
doctor: okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ? patient: other than during the heat and the pollen , it's been pretty good . | D2N071 | 6 | [
"Personal History"
] | [
"Subjective"
] | okay . all right . um , and then i know that you've had that prior lobectomy a couple years ago . any issues with shortness of breath with all the allergies or anything ? | 1,833 |
doctor: okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ? patient: sometimes i , i regularly , uh , go for a run in the morning . that's my workout... | D2N071 | 7 | [
"Vegetative History"
] | [
"Subjective"
] | okay . all right . so i , i know that the nurse went over the review of systems sheet with you , and , and you endorsed some nasal congestion from the pollen , but how about any shortness of breath , cough , muscle aches ? | 1,834 |
doctor: okay , so you also have some shortness of breath with with exertion . patient: correct . correct . | D2N071 | 8 | [
"Vegetative History"
] | [
"Subjective"
] | okay , so you also have some shortness of breath with with exertion . | 1,835 |
doctor: all right , and how far are you running ? patient: uh , like 4 to 5 miles a day . | D2N071 | 9 | [
"Other Socials"
] | [
"Subjective"
] | all right , and how far are you running ? | 1,836 |
doctor: okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure . patient: mm-hmm . | D2N071 | 10 | [
"Physical Examination"
] | [
"Objective"
] | okay , great . all right . well , let's go ahead . i'd like to do a quick physical exam . let's look at your blood pressure . | 1,837 |
doctor: hey , dragon , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , dragon , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it ha... | D2N071 | 11 | [
"Physical Examination",
"Medication"
] | [
"Objective",
"Plan"
] | hey , dragon , show me the vital signs . so here in the office today , your blood pressure looks quite well , at 120 over 80 . let's look at your prior trends . hey , dragon , show me the blood pressure readings . so , yeah , it looks , it looks good . i think you're doing a good job . it looks lower than it has in the... | 1,838 |
doctor: all right , so i'm just gon na listen to your heart and lungs and check you out , okay ? patient: you got it . | D2N071 | 12 | [
"Physical Examination"
] | [
"Objective"
] | all right , so i'm just gon na listen to your heart and lungs and check you out , okay ? | 1,839 |
doctor: okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a ... | D2N071 | 13 | [
"Physical Examination"
] | [
"Objective"
] | okay , so on exam , everything seems to be good . your heart , i hear a slight two out of six systolic ejection murmur , and your lungs sound nice and clear , and you do n't have any lower extremity edema . um , your ... you do have some pain to palpation of the , of the sinuses here , so i think you do have a little b... | 1,840 |
doctor: and in reviewing the results , it looks like your ekg is completely normal , so that's good . patient: good . | D2N071 | 14 | [
"Radiology Examination"
] | [
"Objective"
] | and in reviewing the results , it looks like your ekg is completely normal , so that's good . | 1,841 |
doctor: so i'm not too concerned about that , that chest pounding . hey , dragon , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my as... | D2N071 | 15 | [
"Discussion",
"Radiology Examination",
"Reassessment"
] | [
"Objective",
"Assessment",
"Plan"
] | so i'm not too concerned about that , that chest pounding . hey , dragon , show me the chest x-ray . and we also did a chest x-ray , which , which looks really good , uh , and you know , your prior lobectomy , there's no ... everything looks good , okay ? it looks normal . so let's talk a little bit about my assessment... | 1,842 |
doctor: . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ? patient: uh , actually , i do need a refill . | D2N071 | 16 | [
"Discussion",
"Medication"
] | [
"Plan"
] | . with your current strategy . let's continue you on the prozac 20 milligrams a day and do you need a refill on that ? | 1,843 |
doctor: okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to... | D2N071 | 17 | [
"Discussion",
"Medication",
"Reassessment"
] | [
"Assessment",
"Plan"
] | okay . hey , dragon , order a refill of prozac , 20 milligrams daily . from a ... for your next problem , the lobectomy , i think , you know , i do n't think we need to do any more workup of that . it seems like you're exercising a lot . your breathing function is fine . so , uh , i , i do n't think you need to follow ... | 1,844 |
doctor: you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , dra... | D2N071 | 18 | [
"Discussion",
"Follow-up",
"Diagnostic Testing"
] | [
"Plan"
] | you're doing a great job of keeping it controlled . i know you said you have n't been taking it that much on the weekends , but your blood pressure here looks good , and it's much better over the last several years . so let's go ahead . i do wan na order just , um , an echocardiogram for that murmur . hey , dragon , or... | 1,845 |
doctor: all right . good to see you . patient: same here . | D2N071 | 19 | [
"Chitchat"
] | [
"Null"
] | all right . good to see you . | 1,846 |
doctor: hey , dragon , finalize the note . the nurse will be in . patient: thank you . | D2N071 | 20 | [
"Chitchat"
] | [
"Null"
] | hey , dragon , finalize the note . the nurse will be in . | 1,847 |
doctor: hi , ms. brooks . i'm dr. baker . how are you ? patient: hi , dr. baker . | D2N072 | 0 | [
"Greetings"
] | [
"Subjective"
] | hi , ms. brooks . i'm dr. baker . how are you ? | 1,848 |
doctor: is your , is your right finger hurting ? patient: yes . | D2N072 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | is your , is your right finger hurting ? | 1,849 |
doctor: okay . hey , dragon , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened . patient: well , i was skiing over the weekend- | D2N072 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . hey , dragon , uh , sharon brooks is a 48 year old female here for right finger pain . all right . so , tell me what happened . | 1,850 |
doctor: and when did this happen ? patient: it happened , uh ... that was sunday . | D2N072 | 5 | [
"Acute Symptoms"
] | [
"Subjective"
] | and when did this happen ? | 1,851 |
doctor: okay . and have you tried anything for this or anything made it better or worse ? patient: i tried , um , putting ice on it . | D2N072 | 6 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay . and have you tried anything for this or anything made it better or worse ? | 1,852 |
doctor: okay . and , uh , is it worse when you bend it ? or anything make it ... so , just wh- patient: yeah , movement . | D2N072 | 8 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . and , uh , is it worse when you bend it ? or anything make it ... so , just wh- | 1,853 |
doctor: okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ? patient: um , i have been suffering from constipation recently . | D2N072 | 10 | [
"Acute Symptoms",
"Personal History"
] | [
"Subjective"
] | okay . so , it sounds like you were skiing about four about days ago and you went over a mogul and got it hyper extended or got it bent backwards a little bit , ? okay . do you have any other past medical history at all ? | 1,854 |
doctor: okay . all right . and do you take ... what medicines do you take for constipation ? patient: um , i've just been taking , um , mel- um ... | D2N072 | 11 | [
"Therapeutic History"
] | [
"Subjective"
] | okay . all right . and do you take ... what medicines do you take for constipation ? | 1,855 |
doctor: miralax ? patient: miralax . that's it . | D2N072 | 12 | [
"Therapeutic History"
] | [
"Subjective"
] | miralax ? | 1,856 |
doctor: okay . miralax is sufficient . patient: miralax . yes . | D2N072 | 13 | [
"Therapeutic History"
] | [
"Subjective"
] | okay . miralax is sufficient . | 1,857 |
doctor: and any surgeries in the past ? patient: i did have my appendix taken out when i was 18 . | D2N072 | 14 | [
"Personal History"
] | [
"Subjective"
] | and any surgeries in the past ? | 1,858 |
doctor: okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ? patient: no . | D2N072 | 15 | [
"Physical Examination"
] | [
"Objective"
] | okay . let's do your exam . uh , so , it's this finger right here . and does it hurt here on your , on this joint up here ? | 1,859 |
doctor: okay . and how'bout right there ? no ? patient: no . | D2N072 | 16 | [
"Physical Examination"
] | [
"Objective"
] | okay . and how'bout right there ? no ? | 1,860 |
doctor: right here ? patient: that hurts . | D2N072 | 17 | [
"Physical Examination"
] | [
"Objective"
] | right here ? | 1,861 |
doctor: all right . uh , can you bend your finger for me ? patient: yeah . | D2N072 | 18 | [
"Physical Examination"
] | [
"Objective"
] | all right . uh , can you bend your finger for me ? | 1,862 |
doctor: all right . and how about extend it ? all right . and can you touch your thumb with it ? patient: yes . | D2N072 | 19 | [
"Physical Examination"
] | [
"Objective"
] | all right . and how about extend it ? all right . and can you touch your thumb with it ? | 1,863 |
doctor: all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have... | D2N072 | 20 | [
"Physical Examination",
"Radiology Examination",
"Acute Assessment",
"Medication",
"Other Treatments"
] | [
"Objective",
"Assessment",
"Plan"
] | all right . so , on exam , you do have some tenderness over your distal phalanx , which is the tip of your finger . there is , uh , some tenderness over that joint itself . i do n't feel any tenderness over your proximal joint or your metacarpophalangeal joint , which is right above your knuckle . uh , you have some pa... | 1,864 |
doctor: okay . do you have any questions ? patient: no . i think that sounds good . | D2N072 | 21 | [
"Discussion"
] | [
"Plan"
] | okay . do you have any questions ? | 1,865 |
doctor: okay . hey , dragon , order the medication and procedures we discussed . all right . and why do n't you come with me and we'll get you signed out . patient: okay . thank you . | D2N072 | 22 | [
"Chitchat"
] | [
"Null"
] | okay . hey , dragon , order the medication and procedures we discussed . all right . and why do n't you come with me and we'll get you signed out . | 1,866 |
doctor: all right . finalize report , dragon . | D2N072 | 23 | [
"Chitchat"
] | [
"Null"
] | doctor: all right . finalize report , dragon . | 1,867 |
doctor: today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . hello , how are you ? patient: i'm good , thank you . | D2N073 | 0 | [
"Personal History",
"Greetings"
] | [
"Subjective"
] | today i'm seeing christina cooper . her date of birth is 07/01/1954 . uh , ms. cooper is a new patient who was referred by diane nelson for a long-standing iron deficiency anemia . hello , how are you ? | 1,868 |
doctor: so tell me what brings you in today . patient: recently i tried to donate blood , around december i think , and they told me i was anemic , which is something i've been dealing with for a while , so it's not the first time i've been told i'm anemic . | D2N073 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | so tell me what brings you in today . | 1,869 |
doctor: or how have you been feeling in general with this ? patient: not great . i have been feeling fatigued often during the day , and even feverish with chills at times . when i try to be active i like i ca n't catch my breath and i feel like i'm wheezing . i've had some headaches too , which is not like me . | D2N073 | 2 | [
"Personal History"
] | [
"Subjective"
] | or how have you been feeling in general with this ? | 1,870 |
doctor: okay . are there any other symptoms ? patient: i've been noting some chilling sensations . i also get cold so easily . it's annoying . i feel like i have to really bundle up . i do n't know if this is related but my anxiety and depression feel like it has been getting worse lately . i feel like a mess . | D2N073 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay . are there any other symptoms ? | 1,871 |
doctor: sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ? patient: yeah , i've been anemic since i was 13 years old . | D2N073 | 4 | [
"Personal History"
] | [
"Subjective"
] | sounds like you're not feeling great , obviously . and i'm glad you came to see us . um , we're certainly going to try to figure this out and figure out what's going on , uh , but it sounds like you've been dealing with this anemia for a long time ? | 1,872 |
doctor: right . so why do your doctors think you're anemic ? do you have a history of heavy periods ? patient: well i did have heavy periods until i had a hysterectomy in 1996 . but no , they have not told me why they think i'm anemic , which is frustrating honestly . | D2N073 | 5 | [
"Vegetative History"
] | [
"Subjective"
] | right . so why do your doctors think you're anemic ? do you have a history of heavy periods ? | 1,873 |
doctor: yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ? patient: about five to six years ago . | D2N073 | 6 | [
"Personal History"
] | [
"Subjective"
] | yeah . i can imagine that is . um , let's see if we can help though . since you had your hysterectomy your periods , of course , are no longer the issue . um , when was your last colonoscopy ? | 1,874 |
doctor: and was it relatively a normal exam ? did you have any polyps ? patient: no . they said they'd see me in 10 years . | D2N073 | 7 | [
"Personal History"
] | [
"Subjective"
] | and was it relatively a normal exam ? did you have any polyps ? | 1,875 |
doctor: well that's good news . patient: yeah , i agree . | D2N073 | 8 | [
"Chitchat"
] | [
"Null"
] | well that's good news . | 1,876 |
doctor: um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ? patient: no . | D2N073 | 9 | [
"Vegetative History"
] | [
"Subjective"
] | um , do you have a pacemaker or defibrillator , or have sleep apnea , or use oxygen at night ? | 1,877 |
doctor: all right . do you ever drink alcohol ? patient: yeah , but only once or twice a year . | D2N073 | 10 | [
"Drug History"
] | [
"Subjective"
] | all right . do you ever drink alcohol ? | 1,878 |
doctor: okay . are you taking any supplements such as iron or vitamin b12 ? patient: i already started taking my iron pills which i have not taken in about a year . | D2N073 | 11 | [
"Therapeutic History"
] | [
"Subjective"
] | okay . are you taking any supplements such as iron or vitamin b12 ? | 1,879 |
doctor: all right . and what are you taking ? patient: i'm taking 25 milligram tablets , twice daily . | D2N073 | 12 | [
"Therapeutic History"
] | [
"Subjective"
] | all right . and what are you taking ? | 1,880 |
doctor: okay , and that's the , the ferrous sulfate ? patient: yeah , that's it . i take one in the morning and one in the evening . | D2N073 | 13 | [
"Therapeutic History"
] | [
"Subjective"
] | okay , and that's the , the ferrous sulfate ? | 1,881 |
doctor: okay . anything else ? patient: yeah , i take vitamin b12 , just the over the counter stuff . | D2N073 | 14 | [
"Therapeutic History"
] | [
"Subjective"
] | okay . anything else ? | 1,882 |
doctor: okay , very good . all right , well let's go ahead and take a look and see what's going on . patient: sounds good . thank you . | D2N073 | 15 | [
"Chitchat"
] | [
"Null"
] | okay , very good . all right , well let's go ahead and take a look and see what's going on . | 1,883 |
doctor: of course . you'll hear me , uh , talk through your exam so that i get all the information documented . patient: okay . | D2N073 | 16 | [
"Chitchat"
] | [
"Null"
] | of course . you'll hear me , uh , talk through your exam so that i get all the information documented . | 1,884 |
doctor: all right . so use my general physical exam template . i will start by listening to your heart and lungs . patient: okay . | D2N073 | 17 | [
"Physical Examination"
] | [
"Objective"
] | all right . so use my general physical exam template . i will start by listening to your heart and lungs . | 1,885 |
doctor: all right . next , i'd like you to lay back so i can examine your abdomen . patient: okay . | D2N073 | 18 | [
"Physical Examination"
] | [
"Objective"
] | all right . next , i'd like you to lay back so i can examine your abdomen . | 1,886 |
doctor: is there any tenderness where i'm pressing ? patient: no . | D2N073 | 19 | [
"Physical Examination"
] | [
"Objective"
] | is there any tenderness where i'm pressing ? | 1,887 |
doctor: okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding . patient: is that why they want me to have another upper endoscopy ? | D2N073 | 20 | [
"Physical Examination",
"Acute Assessment"
] | [
"Objective",
"Assessment"
] | okay . you can sit up . so your physical exam is normal without any significant findings . all right ms. cooper , often when we initially see anemia and your host of symptoms , we suspect internal bleeding . | 1,888 |
doctor: actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why . patient: lovely . | D2N073 | 21 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | actually it would be an upper endoscopy and a colonoscopy , but yes , likely that's the reason why . | 1,889 |
doctor: yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . patient: okay . | D2N073 | 22 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | yeah . unfortunately our cameras do not meet all the way in the middle , so if those tests back , come , if those tests come back fine , then we'll have you swallow a pill camera to take pictures as it moves through your , uh , system . | 1,890 |
doctor: we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . pa... | D2N073 | 23 | [
"Discussion",
"Referral",
"Medication"
] | [
"Plan"
] | we may not need to , but it's just the first thing we can do to make sure that you're not losing blood . um , the second thing we can do is have you see a hematologist . they will tell us if you need to give any , to give you any intravenous iron , or maybe something to help your body store the iron better . | 1,891 |
doctor: so let's go ahead , get your upper endoscopy and colonoscopy scheduled . patient: okay . | D2N073 | 24 | [
"Diagnostic Testing"
] | [
"Plan"
] | so let's go ahead , get your upper endoscopy and colonoscopy scheduled . | 1,892 |
doctor: um , have you ever had any issue with sedation in the past ? patient: no , i was just sleepy afterwards . | D2N073 | 25 | [
"Personal History"
] | [
"Subjective"
] | um , have you ever had any issue with sedation in the past ? | 1,893 |
doctor: okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . patient: okay . sounds like a plan . | D2N073 | 26 | [
"Medication",
"Diagnostic Testing"
] | [
"Plan"
] | okay . well we will give you a bowel prep to clean out your bowels ahead of time . um , if we do these tests and they are normal , like i said , then we will consider that capsule endoscopy . | 1,894 |
doctor: all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work ... | D2N073 | 27 | [
"Follow-up",
"Referral",
"Medication"
] | [
"Plan"
] | all right . so after that you'll be all done and we will send you to the hematologist . additionally , i'm going to need you to start taking your iron pills with orange juice . uh , the vitamin c will help you absorb the iron better . do this for about 8-12 weeks , uh , and then we can reassess your blood work . | 1,895 |
doctor: all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if y... | D2N073 | 28 | [
"Discussion",
"Referral",
"Medication",
"Diagnostic Testing"
] | [
"Plan"
] | all right . well i think we have our plan . on your way out , stop by and schedule your upper endoscopy and c- colonoscopy . uh , we will send a referral to dr. flores who is is the hematologist , so schedule that appointment . um , here are your instructions for the pre- uh , the bowel prep . uh , call us if you have ... | 1,896 |
doctor: you're welcome . have a great day , have a great day ms. cooper . patient: you too . | D2N073 | 29 | [
"Chitchat"
] | [
"Null"
] | you're welcome . have a great day , have a great day ms. cooper . | 1,897 |
doctor: all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um ,... | D2N073 | 30 | [
"Personal History",
"Therapeutic History",
"Lab Examination",
"Diagnostic Testing",
"Referral"
] | [
"Subjective",
"Objective",
"Assessment",
"Plan"
] | doctor: all right . this is christina cooper , pleasant 65 year old female who was diagnosed with iron deficiency anemia in 12-2019 , and w- and was unable to donate blood . um , her followup blood work on 01/20/20 was revealed a low hemoglobin , stable hematocrit and normal iron labs , although ferritin was low . um ,... | 1,898 |
doctor: patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care prov... | D2N074 | 0 | [
"Personal History",
"Greetings"
] | [
"Subjective"
] | patient , bruce ward . date of birth 5/21/1969 . please use my neuro consult template . this is a 52-year-old male with dia- newly diagnosed pituitary lesion . the patient is seen in consultation at the request of dr. henry howard for possible surgical intervention . mr . ward presented to his primary care provider , d... | 1,899 |
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