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DATEXIS
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aci_bench_intent_annotated

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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 the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar . yeah ... i-i love peanut butter cups . um ... and i have to say that when we were helping my daughter , we were on the fly and on the go and haven't had a home cooked meal in weeks, our diets were less than stellar .
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 , but it's been pretty good and-and under control for the most part .
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 . not great , but it's been okay .
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 ? patient: mm-hmm .
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 with all the pollen and everything and , uh , we dropped my oldest daughter off at college and moved her into her dorm , so little stressful , little chaotic , in the heat of the summer , but so far , so good .
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 good , and everything's managed and maintained . um , still kind of working with my hypertension . that's been a little bit more of a struggle than anything .
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 to bring it with me . uh , but for the most part , it's been okay .
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 , and sometimes if it's , uh , relatively humid , i'll struggle a little bit , and i might feel a little bit of pounding in my chest . it usually goes away , but , uh , again , for the most part , it's been pretty good .
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 has in the past , so continue on the current medication . patient: mm-hmm .
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 past , so continue on the current medication .
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 little bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today . patient: mm-hmm .
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 bit of congestion there . let's go ahead and look at some of your results , okay ? hey , dragon , show me the ekg . so they did an ekg before you came in today .
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 assessment and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well- patient: mm-hmm .
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 and my plan for you . so for your first problem , your , your depression , it seems , again , like you're doing really well-
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 follow up with the surgeon anymore . and then for your last problem , your hypertension . patient: mm-hmm .
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 up with the surgeon anymore . and then for your last problem , your hypertension .
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 , dragon , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ? patient: perfect .
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 , order an echocardiogram . and i'll just follow up with the results , and we'll go ahead and order , um , your routine blood work , and i'll be in touch with you through the patient portal , okay ?
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 some pain flexion as well . so , let's look at your x-rays . hey , dragon , show me the x-rays . all right . so , on this x-ray.everything looks normal right now . uh , i do n't see any fractures . everything lines up pretty well . uh , so , your x-ray looks normal with no fractures . so , based on the x-ray and your exam , you have some tenderness right here . i think you've got a little contusion right here . there's no fracture on the tip of your finger . uh , so , the diagnosis would be a right hand , uh , index finger contusion on the tip of your finger , okay ? so , i would recommend we get you a s- uh , aluminum foam splint and we'll get you some motrin . uh , we'll give you 600 milligrams every six hours and we'll take that for about a week . and if it does n't get better , why do n't you call us and come back at that point ? patient: okay .
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 pain flexion as well . so , let's look at your x-rays . hey , dragon , show me the x-rays . all right . so , on this x-ray.everything looks normal right now . uh , i do n't see any fractures . everything lines up pretty well . uh , so , your x-ray looks normal with no fractures . so , based on the x-ray and your exam , you have some tenderness right here . i think you've got a little contusion right here . there's no fracture on the tip of your finger . uh , so , the diagnosis would be a right hand , uh , index finger contusion on the tip of your finger , okay ? so , i would recommend we get you a s- uh , aluminum foam splint and we'll get you some motrin . uh , we'll give you 600 milligrams every six hours and we'll take that for about a week . and if it does n't get better , why do n't you call us and come back at that point ?
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 . patient: all right .
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 . patient: okay , that sounds great .
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 you have any questions or worsening symptoms . we'll be happy to help you . patient: thank you .
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 any questions or worsening symptoms . we'll be happy to help you .
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 , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .
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 , she was taking ferrous sulfate , three hundred , twenty phil- 25 milligrams by mouth . i've asked her to continue each dose with vitamin c found in orange juice , for the next 12 weeks , then recheck to the cbc , iron , ferritin , b12 , and folate . um , a referral was sent to her hematologist . we will plan for an egd and a colonoscopy to assess for potential sources of anemia or gi bleed . if this is inconclusive , capsule endoscopy will be considered . thanks .
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 provider , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable . worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . the mri reveals a pituitary lesion with elevation and compression of the optic chiasm . the ventricles are normal in size and no other abnormalities are lo- are noted . hello , mr . ward . nice to meet you . i'm dr. flores . patient: hi , doc . nice to meet you .
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 , dr. howard , on 3/1/21 complaining of worsening headaches over the past few months . he denied any trouble with headaches in the past . his past clinical history is unremarkable . worked out for worsening headaches was initiated with brain mri and serology where pituitary lesion was incidentally discovered . i personally reviewed the labs dated 3/3/21 including cbc , unes , uh , coagulation , and crp . all were normal . pituitary hormone profile demonstrates a low tsh , all other results were normal . um , i personally reviewed pertinent radiology studies including mri for the brain with contrast from 3/4/21 . the mri reveals a pituitary lesion with elevation and compression of the optic chiasm . the ventricles are normal in size and no other abnormalities are lo- are noted . hello , mr . ward . nice to meet you . i'm dr. flores .
1,899