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doctor: okay any questions for me patient: i do n't believe so at this time
D2N081
15
[ "Discussion" ]
[ "Plan" ]
okay any questions for me
2,100
doctor: okay alright so i'll see you at your next visit patient: great thank you
D2N081
16
[ "Chitchat" ]
[ "Null" ]
okay alright so i'll see you at your next visit
2,101
doctor: you're welcome and so now just
D2N081
17
[ "Chitchat" ]
[ "Null" ]
doctor: you're welcome and so now just
2,102
doctor: hi kyle how are you today patient: i'm doing well i'm just anxious about my pcp told me that i had some abnormal lab work and why she wanted me to be seen by you today
D2N082
0
[ "Greetings" ]
[ "Subjective" ]
hi kyle how are you today
2,103
doctor: yeah i bet that did make you nervous i i see that she referred you for a low immunoglobulin a level is that your understanding patient: yeah i mean i do n't even really understand what that means but yeah that's what she told me
D2N082
1
[ "Personal History" ]
[ "Subjective" ]
yeah i bet that did make you nervous i i see that she referred you for a low immunoglobulin a level is that your understanding
2,104
doctor: yeah that's a mouthful patient: yeah
D2N082
2
[ "Chitchat" ]
[ "Null" ]
yeah that's a mouthful
2,105
doctor: it it's the the one of the antibodies in your body and that that really makes that your body makes to fight infections it's a little bit low i'm happy to explain it a little bit more to you i just have a few more questions okay so let's start again here patient: i'll do this
D2N082
3
[ "Discussion" ]
[ "Plan" ]
it it's the the one of the antibodies in your body and that that really makes that your body makes to fight infections it's a little bit low i'm happy to explain it a little bit more to you i just have a few more questions okay so let's start again here
2,106
doctor: i i think i would break that patient: yeah i just saw that
D2N082
4
[ "Chitchat" ]
[ "Null" ]
i i think i would break that
2,107
doctor: if you can do that patient: okay
D2N082
5
[ "Chitchat" ]
[ "Null" ]
if you can do that
2,108
doctor: yeah so we'll we'll just patient: okay
D2N082
6
[ "Chitchat" ]
[ "Null" ]
yeah so we'll we'll just
2,109
doctor: you can leave it the way it is for now i just i think break that up patient: okay alright so yeah that sounds fine for me
D2N082
7
[ "Chitchat" ]
[ "Null" ]
you can leave it the way it is for now i just i think break that up
2,110
doctor: yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections patient: yeah yeah i had a recent physical and she did this as part of her my physical i do tend to get infections but i do n't know i i'm so used to it so i do n't know if this is more than usual in the wintertime i get a lot of colds and they do seem to i always say that my colds kind of linger for a long time but i do n't know if it's more than usual
D2N082
8
[ "Personal History" ]
[ "Subjective" ]
yeah i do you know why she checked these levels in the first place that you've been having problems getting frequent infections
2,111
doctor: okay how about any abdominal infections patient: diarrhea no
D2N082
9
[ "Personal History" ]
[ "Subjective" ]
okay how about any abdominal infections
2,112
doctor: frequently patient: no not that i can not that i say can think of
D2N082
10
[ "Personal History" ]
[ "Subjective" ]
frequently
2,113
doctor: okay what about your family are are anyone in your family that you know have immune deficiencies patient: no my family is actually pretty healthy
D2N082
11
[ "Family History" ]
[ "Subjective" ]
okay what about your family are are anyone in your family that you know have immune deficiencies
2,114
doctor: okay and how about do you have any other medical conditions patient: yeah my pcp just started me on metformin i just got diagnosed with type two diabetes
D2N082
12
[ "Personal History" ]
[ "Subjective" ]
okay and how about do you have any other medical conditions
2,115
doctor: okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street patient: yes and that's probably part of the cause of my diabetes yes
D2N082
13
[ "Family History", "Other Socials" ]
[ "Subjective" ]
okay okay yeah diabetes your family your family owns that donut shop right i mean down at the end of the street
2,116
doctor: yeah well i guess you're gon na have to watch that patient: i know i know
D2N082
14
[ "Discussion" ]
[ "Plan" ]
yeah well i guess you're gon na have to watch that
2,117
doctor: but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away patient: right
D2N082
15
[ "Discussion" ]
[ "Plan" ]
but you know everything in moderation i mean just you know you just need to be careful you ca n't does n't have to go away
2,118
doctor: but have you ever needed to receive a blood transfusion or blood products patient: no i actually tried to give blood but they i did n't qualify because i had recently traveled internationally
D2N082
16
[ "Personal History" ]
[ "Subjective" ]
but have you ever needed to receive a blood transfusion or blood products
2,119
doctor: okay where did you go patient: i was in zambia
D2N082
17
[ "Other Socials" ]
[ "Subjective" ]
okay where did you go
2,120
doctor: hmmm i heard that's beautiful patient: it's so beautiful it's so beautiful i had a great time
D2N082
18
[ "Chitchat" ]
[ "Null" ]
hmmm i heard that's beautiful
2,121
doctor: okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial patient: no
D2N082
19
[ "Physical Examination", "Vegetative History" ]
[ "Subjective", "Objective" ]
okay well let me let me go ahead and do a physical examination here i reviewed your vitals you know that the the assistants collected when you first came in including your weight and everything looks good there there is no fever there there is nothing that i'm concerned about there now on your heart exam you have a nice regular rate and rhythm and i do n't appreciate any murmurs that's kind of those extra sounds that i would hear and that that all sounds good on lungs lung exam your lungs are clear there's no wheezes rales or rhonchi now on your neck exam i do n't appreciate any lymph lymphadenopathy swollen lymph glands and then let me just go ahead and i wan na press on your belly a little bit is that tender anywhere that i press it does n't seem like you making any facial
2,122
doctor: no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about the assessment and plan so for your first problem the that a iga deficiency is it very common immunodeficiency your your body makes many different types of antibodies in one of your z iga is just a little bit lower than normal now most of the time people live their entire life without even knowing they have that deficiency and function perfectly normal now some people may find that they get tend to get frequent respiratory tract or sinus or abdominal infections but this does n't necessarily seem to be the case for you now it can go along with other immunodeficiencies but i think there is a low likelihood hood in your case but we're gon na order some additional blood work that includes checking those other antibodies now do you have any questions on what i just told you patient: yeah so is there anything i need to do or should be watching for or should i be worried
D2N082
20
[ "Physical Examination", "Discussion", "Acute Assessment", "Lab Examination" ]
[ "Objective", "Assessment", "Plan" ]
no okay so your you know your abdominal exam is your belly is soft there is no tenderness as i i push around there now i did review the results of your recent lab work and it is consistent as as your pcp noted with an iga deficiency that's that immunoglobulin a that we talked about so let me tell you a little bit about the assessment and plan so for your first problem the that a iga deficiency is it very common immunodeficiency your your body makes many different types of antibodies in one of your z iga is just a little bit lower than normal now most of the time people live their entire life without even knowing they have that deficiency and function perfectly normal now some people may find that they get tend to get frequent respiratory tract or sinus or abdominal infections but this does n't necessarily seem to be the case for you now it can go along with other immunodeficiencies but i think there is a low likelihood hood in your case but we're gon na order some additional blood work that includes checking those other antibodies now do you have any questions on what i just told you
2,123
doctor: no i i really do n't think you need to be worried now we're gon na check these additional studies and that will give us some more guidance but really i think this is just a finding that's common to you and you know it it's many people have have have these type of you know immunodeficiency what i want you to watch for is those infections that do n't stop you have trouble getting it under control or you know any changes to your abdominal tract you know severe diarrhea anything like that then you know we may want to look at it a little bit further but for now i do n't think there is anything significant we want to do now go ahead and get your lab work and bring you in for that now the only other thing that i would say is if you eat end up needing any blood products between now and when i see you next make sure you tell them that you have that iga deficiency patient: why is that
D2N082
21
[ "Discussion", "Diagnostic Testing" ]
[ "Plan" ]
no i i really do n't think you need to be worried now we're gon na check these additional studies and that will give us some more guidance but really i think this is just a finding that's common to you and you know it it's many people have have have these type of you know immunodeficiency what i want you to watch for is those infections that do n't stop you have trouble getting it under control or you know any changes to your abdominal tract you know severe diarrhea anything like that then you know we may want to look at it a little bit further but for now i do n't think there is anything significant we want to do now go ahead and get your lab work and bring you in for that now the only other thing that i would say is if you eat end up needing any blood products between now and when i see you next make sure you tell them that you have that iga deficiency
2,124
doctor: well there is a risk that your body can strongly react to some blood products and they just need to know that so they're prepared so anytime you get blood just make sure you say that you have a history of a an an iga deficiency patient: okay okay thank you
D2N082
22
[ "Discussion" ]
[ "Plan" ]
well there is a risk that your body can strongly react to some blood products and they just need to know that so they're prepared so anytime you get blood just make sure you say that you have a history of a an an iga deficiency
2,125
doctor: you're welcome patient: okay
D2N082
23
[ "Chitchat" ]
[ "Null" ]
you're welcome
2,126
doctor: hey lawrence how're you doing patient: i'm doing alright aside from this elbow pain
D2N083
0
[ "Greetings" ]
[ "Subjective" ]
hey lawrence how're you doing
2,127
doctor: so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain patient: so i really during this pandemic i really got into ceramics and doing pottery so i've been doing a lot of pottery and over the past week i then started to develop this elbow pain
D2N083
1
[ "Acute Symptoms" ]
[ "Subjective" ]
so it looks like here that you came in to see us today for an evaluation of that right elbow pain can you tell me can you can you tell me well first of all what do you think has been causing that pain
2,128
doctor: okay and then so tell me a little bit more about that elbow pain where does it hurt exactly patient: you know it hurts a lot in the inside of my elbow
D2N083
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and then so tell me a little bit more about that elbow pain where does it hurt exactly
2,129
doctor: okay so the inside of your right elbow okay patient: yeah
D2N083
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay so the inside of your right elbow okay
2,130
doctor: and then does the pain radiate down your arm or up into your shoulder or anything like that patient: it does n't go into my shoulder it's it stays mostly at my elbow but it can go down a bit into my forearm
D2N083
4
[ "Acute Symptoms" ]
[ "Subjective" ]
and then does the pain radiate down your arm or up into your shoulder or anything like that
2,131
doctor: okay and then do you remember any trauma did you hit your arm or elbow or any on anything patient: no nothing i i really was trying to think if there is anything else and i ca n't think of anything
D2N083
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and then do you remember any trauma did you hit your arm or elbow or any on anything
2,132
doctor: okay and you've never injured that right elbow before patient: no
D2N083
6
[ "Personal History" ]
[ "Subjective" ]
okay and you've never injured that right elbow before
2,133
doctor: alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life patient: i would say probably a six
D2N083
7
[ "Acute Symptoms" ]
[ "Subjective" ]
alright so now let's talk a little bit about your pain and how bad it how bad is that pain on a scale from zero to ten ten being the worst pain you've ever felt in your life
2,134
doctor: okay and does that pain keep you up at night patient: it does
D2N083
8
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and does that pain keep you up at night
2,135
doctor: okay and when you have that kind of pain does it keep you from doing other type of activities patient: yeah i mean i still try to like work through with using my arm but yeah it's it's it's difficult for me sometimes to lift and do things because of that pain
D2N083
9
[ "Other Socials" ]
[ "Subjective" ]
okay and when you have that kind of pain does it keep you from doing other type of activities
2,136
doctor: okay and then and how long has this pain been going on patient: about four days now
D2N083
10
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and then and how long has this pain been going on
2,137
doctor: alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief patient: i've tried ibuprofen that helps a little but not much
D2N083
11
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
alright and anything you've done to help relieve or alleviate that pain any anything that that's giving you relief
2,138
doctor: okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here patient: yes i do
D2N083
12
[ "Physical Examination" ]
[ "Objective" ]
okay so if it's okay with you i would like to do a a quick physical exam your vitals look good and i'm gon na do a focused exam on that right elbow i'm gon na go ahead and and and press here do you do you have any pain when i press here
2,139
doctor: okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that patient: not really
D2N083
13
[ "Physical Examination" ]
[ "Objective" ]
okay so you are positive for pain to palpation you do note that moderate tenderness of the medial epicondyle now i'm gon na have you turn your wrist as if you're turning a door knob do you have any pain when you do that
2,140
doctor: okay now turn your wrist in so do you have any pain when you do that patient: yeah that hurts
D2N083
14
[ "Physical Examination" ]
[ "Objective" ]
okay now turn your wrist in so do you have any pain when you do that
2,141
doctor: okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist patient: yes i do
D2N083
15
[ "Physical Examination" ]
[ "Objective" ]
okay so you do have pain you were positive for pain when you pronate that that that forearm okay i'm gon na go ahead and have you rest your arm on the table here palm side up now i want you to raise your hand by bending at the wrist and i'm gon na put some resistance against it do you have any pain when i press against your flexed wrist
2,142
doctor: alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay patient: alrighty
D2N083
16
[ "Follow-up", "Medication", "Other Treatments", "Radiology Examination", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
alright so you are positive for pain with resistance against flexion of that left wrist so i let let's go ahead and review the x-ray that we did of your elbow the good news is i do n't see any fracture or bony abnormality of that right elbow which is good so let's talk a little bit about my assessment and plan for you so for the problem with elbow pain i do believe that this is consistent with medial epicondylitis which is caused by the overuse and potential damage of those tendons that bend that that bend the wrist towards the palm now i want you to rest it i'm gon na order a sling and i want you to wear the sling while you're awake now we're also gon na have you apply ice to the elbow for twenty minutes three times a day and i want you to take ibuprofen that's gon na be six hundred milligrams q.6 h. with food and i want you to take that for a full week now you're not gon na like this part but i want you to hold off for the next couple of weeks on doing any type of pottery work okay alright now what i wan na do is i wan na see you again in a week and i wan na see how you're doing okay
2,143
doctor: alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week patient: alright thank you
D2N083
17
[ "Follow-up" ]
[ "Plan" ]
alrighty so i'll have the nurse come in and get you set up with that sling and i will see you again in about a week
2,144
doctor: thank you
D2N083
18
[ "Chitchat" ]
[ "Null" ]
doctor: thank you
2,145
doctor: alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened patient: well it seems that i was outside and i fell down i was walking a bit and i did have a pain in my chest but i did n't think anything of it and i just kept on going and then all of a sudden i'm here
D2N084
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
alright david so you were just in the emergency department hopefully you can hear me okay through the zoom meeting what happened
2,146
doctor: hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath patient: i did but i did n't think anything of it
D2N084
1
[ "Acute Symptoms" ]
[ "Subjective" ]
hmmm my gosh so it looks like you you went into the er and looks like they said that your ankles were swelling a little bit too and did you have some shortness of breath
2,147
doctor: sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on patient: i have but i miss them every year and then so i think today i took one
D2N084
2
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
sure yeah okay yeah i know we've been talking through your hypertension looks like your blood pressure was two hundred over ninety have you been taking those meds that we have you on
2,148
doctor: okay alright yeah i have you on bumex cozaar and norvasc does that sound right patient: i guess so that sounds about right
D2N084
3
[ "Therapeutic History" ]
[ "Subjective" ]
okay alright yeah i have you on bumex cozaar and norvasc does that sound right
2,149
doctor: alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that patient: i've just been eating anything honestly i try to watch it here and there but to tell you the truth i'd looks i was eating
D2N084
4
[ "Personal History" ]
[ "Subjective" ]
alright okay yeah you need to make sure that you're you're taking those consistently that's really important and i know that we talked a little bit about watching your diet how have you been doing with that
2,150
doctor: yeah i i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or patient: little bit of everything here and there i do lot of chips
D2N084
5
[ "Personal History" ]
[ "Subjective" ]
yeah i i know it's hard around the holidays and everything but it is really important that we watch that diet what kind of things are you eating is it is it salty foods or pizza chicken wing kinda stuff or what are you standing or
2,151
doctor: mm-hmm patient: kinda whatever i can get my hands on really
D2N084
7
[ "Vegetative History" ]
[ "Subjective" ]
mm-hmm
2,152
doctor: okay alright how are you feeling right now patient: i'm doing a little okay i guess i'm just out of breath a little bit but it's nothing i ca n't handle
D2N084
8
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright how are you feeling right now
2,153
doctor: sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those patient: no i have n't got one yet i know i needed to get one
D2N084
9
[ "Personal History" ]
[ "Subjective" ]
sure yeah okay so you're taking your meds mostly we talked about getting you a blood pressure cuff at home did you end up getting one of those
2,154
doctor: yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately patient: just like i said when i was walking outside it helped a little bit but again i just walked it off
D2N084
10
[ "Vegetative History" ]
[ "Subjective" ]
yeah that's that will be good if you can take your blood pressures at home and definitely track those what about any problems with shortness of breath lately
2,155
doctor: sure any problems sleeping patient: no i sleep like a rock
D2N084
11
[ "Vegetative History" ]
[ "Subjective" ]
sure any problems sleeping
2,156
doctor: good good to hear have you had any chest pain patient: slightly here or there but i thought it was just heartburn
D2N084
12
[ "Vegetative History" ]
[ "Subjective" ]
good good to hear have you had any chest pain
2,157
doctor: sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that patient: i've been pretty good on it very once every week maybe just one
D2N084
13
[ "Physical Examination", "Drug History" ]
[ "Objective" ]
sure okay alright let me do a quick physical exam your blood pressure is pretty good in the office today it looks like it's one twenty eight over seventy two your other vital signs look good on your neck exam there is no jugular venous distention on your heart exam just gon na take a listen here i do appreciate a two out of six systolic ejection murmur but i heard that before and that is stable your lungs you want to take a deep breath for me lungs are clear bilaterally now i know we talked about you stopping smoking a a couple of years ago i have here have you kept up with that
2,158
doctor: okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay patient: that sounds good document
D2N084
14
[ "Medication", "Other Treatments", "Radiology Examination", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
okay alright good to hear alright and your lower extremities show a trace edema so megan david david i'm looking at your results of your echocardiogram that you got when you were in the er and it it does show preserved ejection fraction of fifty five percent and normal diastolic filling and mild to moderate mild to moderate mitral regurgitation so let me tell you about what that means for the chf that you were in the hospital with sounds like you know based on your diet this is likely caused by your dietary indiscretion and uncontrolled hypertension that we've been monitoring so what i want you to do is continue your bumex two milligrams once daily definitely stay on top of that make sure that you get those meds in every time i'm gon na write you a consult to nutrition since it sounds like maybe we can give you some advice on on watching your diet definitely watching the salty foods that you've been eating does that sound okay
2,159
doctor: awesome weigh yourself daily do you have a scale at home patient: no but i can get one
D2N084
15
[ "Discussion" ]
[ "Plan" ]
awesome weigh yourself daily do you have a scale at home
2,160
doctor: okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good patient: that sounds good to me
D2N084
16
[ "Medication", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
okay good get a scale weigh yourself daily call me if you gain three pounds in two days for the hypertension that we've been treating i want you to continue the cozaar one hundred milligrams daily continue the norvasc five milligrams once daily so i'll be written down in your discharge summary and i'm gon na order a test i'm gon na order a renal artery ultrasound just to make sure that we're not missing anything there does that sound good
2,161
doctor: great okay david do you have any other questions patient: no other questions at this time just i guess i just need to make sure to take my medication on time that's about it
D2N084
17
[ "Discussion" ]
[ "Plan" ]
great okay david do you have any other questions
2,162
doctor: yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well patient: i will do my best
D2N084
18
[ "Discussion", "Medication", "Other Treatments" ]
[ "Plan" ]
yeah definitely take your medication on time and see that nutritionist and hopefully we can get your get your diet on track as well
2,163
doctor: alright thanks hope you feel better patient: thank you
D2N084
19
[ "Chitchat" ]
[ "Null" ]
alright thanks hope you feel better
2,164
doctor: hi russell how are you what's been going on patient: well i've been having this sharp pain on the right side of my abdomen below my ribs for the last several days i saw my doctor and they ordered a cat scan and said i had a kidney stone and sent me to see a urologist
D2N085
0
[ "Greetings" ]
[ "Subjective" ]
hi russell how are you what's been going on
2,165
doctor: okay well does the pain move or or or go anywhere or does it stay right in that same spot patient: yeah it feels like it goes to my lower abdomen in into my groin
D2N085
1
[ "Acute Symptoms" ]
[ "Subjective" ]
okay well does the pain move or or or go anywhere or does it stay right in that same spot
2,166
doctor: okay and is the pain constant or does it come and go patient: it comes and goes when it comes it's it's pretty it's pretty bad i feel like i ca n't find a comfortable position
D2N085
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and is the pain constant or does it come and go
2,167
doctor: okay and do you notice any any pain when you urinate or when you pee patient: yeah it kinda burns a little bit
D2N085
3
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
okay and do you notice any any pain when you urinate or when you pee
2,168
doctor: okay do you notice any blood patient: i do n't think there is any you know frank blood but the urine looks a little dark sometimes
D2N085
4
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
okay do you notice any blood
2,169
doctor: okay and what have you taken for the pain patient: i have taken some tylenol but it has n't really helped
D2N085
5
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay and what have you taken for the pain
2,170
doctor: okay and do you have any nausea vomiting any fever chills patient: i feel nauseated but i'm not vomiting
D2N085
6
[ "Vegetative History" ]
[ "Subjective" ]
okay and do you have any nausea vomiting any fever chills
2,171
doctor: okay is anyone in your in your family had kidney stones patient: yes my father had them
D2N085
7
[ "Family History" ]
[ "Subjective" ]
okay is anyone in your in your family had kidney stones
2,172
doctor: and have you had kidney stones before patient: yeah so i i've i've had them but i've been able to pass them but this is taking a lot longer
D2N085
8
[ "Personal History" ]
[ "Subjective" ]
and have you had kidney stones before
2,173
doctor: okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay patient: okay
D2N085
9
[ "Physical Examination" ]
[ "Objective" ]
okay well i'm just gon na go ahead and do a physical examination i'm gon na be calling out some of my exam findings and i'm going to explain what what those mean when i'm done okay
2,174
doctor: okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay patient: okay sounds good thank you
D2N085
10
[ "Physical Examination", "Diagnostic Testing", "Acute Assessment", "Follow-up", "Other Treatments", "Radiology Examination", "Medication" ]
[ "Objective", "Assessment", "Plan" ]
okay so on physical examination of the abdomen on a abdominal exam there is no tenderness to palpation there is no evidence of any rebound or guarding there is no peritoneal signs there is positive cva tenderness on the right flank so essentially what that means russell is that you know you have some tenderness over your over your right kidney and that just means that you might have some inflammation there so i i reviewed the results of the ct scan of your abdomen that the primary care doctor ordered and it does show a . five centimeter kidney stone located in the proximal right ureter so this the ureter is the duct in which urine passes between the kidney and the bladder there's no evidence of what we call hydronephrosis this means you know swelling of the kidney which is good means that things are still able to get through so let's talk a little bit about my assessment and my plan okay so for your first problem of this acute nephrolithiasis or kidney stone i i wan na go ahead and recommend that you push fluids to help facilitate urination and peeing to help pass the stone i'm going to prescribe oxycodone five milligrams every six to eight hours as needed for pain you can continue to alternate that with some tylenol i'm going to give you a strainer that you can use to strain your urine so that we can see it see the stone when it passes and we can send it for some some tests if that happens i'm also gon na order what we call a basic metabolic panel a urinalysis and a urine culture now i wan na see you again in one to two weeks and if you're still having symptoms we'll have to discuss further treatment such as lithotripsy which is essentially a shock wave procedure in which we sedate you and use shock waves to break up the stone to help it pass we could also do what we call a ureteroscopy which is a small telescope small camera used to go up to to the urethra and bladder and up into the ureter to retrieve the stone so let's see how you do over the next week and i want you to contact me if you're having worsening symptoms okay
2,175
doctor: hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that patient: yeah i've had the boot for about six weeks i first noticed it when i put on a pair of shoes that were little bit too tight i felt some burning and some stinging and looked down and saw a blister i did n't think too much of it because it was on the pad of the bottom of my foot around my heel and i just had been walking on the front part of my foot i started to notice a foul smell and my wife mentioned something to me the other day and i noticed my dog was also smelling my socks a lot and so we looked and saw that the blister had become unroofed or the the top part of the skin of the blister became undone and then underneath it was just this really thick soft mushy skin that had a bad smell with some yellow drainage and so and barbara called the primary care doctor who then got me in to see you he started me on some antibiotics about six days ago and i never had any nausea or vomiting but my wife checked my temperature it was about ninety nine point seven and then at one point i had to put on an extra blanket in bed because i had some chills and when i started the antibiotics it started to feel pretty good but we've now noticed that it has turned black around the outside of the wound and i'm getting some cramping in my calf muscle as well and so there was a red streak also that was coming up the front part of my my ankle along the inside portion of my calf muscle and it's super super hot and so they wanted me to take a have have you look at it
D2N086
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hey nicholas nice to see you today your pcp looks like he sent you over for a nonhealing foot ulcer on your right foot can you tell me about how long you've had that
2,176
doctor: okay thank you for sharing that history with me and did you complete that course of antibiotics patient: i think he called in ten days' worth and i'm on day six or seven right now i know i've got about two or three days left
D2N086
1
[ "Therapeutic History" ]
[ "Subjective" ]
okay thank you for sharing that history with me and did you complete that course of antibiotics
2,177
doctor: okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now patient: yeah it was it was stinging initially like i had just done something small but at this point it's it's really like throbbing it's almost like there is a fire poker in the bottom of my foot now and then the inside of my calf muscle is really hard and i've noticed that every time that i push that i feel it all the way up to my knee behind my kneecap and then noticed that i've been coughing a lot the last two days and then i've noticed that i've had like difficult time catching my breath when i'm walking around the house and so it's almost like two different things going on at this point
D2N086
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay and you mentioned that it had some stinging and it was a bit uncomfortable are you experiencing any pain right now
2,178
doctor: okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that patient: yeah my my a1c is six point seven it's pretty well controlled
D2N086
3
[ "Personal History" ]
[ "Subjective" ]
okay so now i see here in your record that you have some that you're diabetic and have some diabetic neuropathy as well how's your blood sugars been running i'm i'm assuming kind of all over the place over the last i'm gon na say probably three or four weeks can you tell me about that
2,179
doctor: okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park patient: yeah we actually hiked to charlie's bunion about a week before this i've had a new pair of diabetic shoes and inserts i get those every year i changed the inserts every three or four months i mean i've been in cruise control as far as that goes for some time i did get a new pair of shoes the prosthetist told me to check my feet every day for the first week or two which we did i did go hiking about the third or fourth day and i think that might be what caused it as i just went too far when we were hiking but yeah the trails are the trails are gorgeous they're open it's time to to be outside and i'm sorta stuck with this right now
D2N086
5
[ "Other Socials" ]
[ "Subjective" ]
okay now i know this was caused by a new pair of shoes you had mentioned before to your pcp and he relayed this to me that you really like to go on hikes you and your wife have been hiking have you gone to the new trails that that were just opened up here behind the park
2,180
doctor: absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there patient: i do n't feel that right there
D2N086
6
[ "Physical Examination" ]
[ "Objective" ]
absolutely yeah my wife and i like to go back there and and hike those trails as well so i'm gon na do a quick physical exam for your vital signs i do recognize a slight fever however your vitals themselves look good now on your foot exam i do recognize the necrotic wound on your heel as you mentioned it is present it's approximately two by two centimeters i i do recognize the sloughing of the of the tissue as well as what looks like cellulitis around the area as well as erythemia so now unfortunately i do also smell the odor you are correct it is it does it is odds but i do not appreciate any bony exposure now on vascular exam i do have bilateral palpable pulses femorally and popliteal pulses are present however i do n't recognize a palpable pulse dorsalis pedis or posterior tibial however i did use the doppler and they are present via doppler now i'm gon na press on the actual affected area of the wound do you have any pain there
2,181
doctor: okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure patient: no not really so you're gon na continue the antibiotics that i'm on and possibly extend or call in a new antibiotic depending on the culture
D2N086
7
[ "Follow-up", "Medication", "Radiology Examination", "Diagnostic Testing", "Reassessment", "Acute Assessment" ]
[ "Objective", "Assessment", "Plan" ]
okay i'm gon na review the results of your right foot x-ray that we did when you came in today the good news is i do n't see any evidence of osteomyelitis meaning that there is no infection of the bone so let's talk a little bit about my assessment and plan for this nonhealing diabetic foot ulcer i'm going to order a test to check blood supply for this wound also i'm going to do a debridement today in the office we may have to look at we are going to do a culture and we may have to look at different antibiotic therapy i am concerned about the redness that's moving up your leg as well as this the the swelling and pain that you have in your calf so we're gon na monitor this very closely i wan na see you again in seven days and then as far as your diabetes is concerned i do want you to follow up with your endocrinologist and make sure that we do continue to keep your hemoglobin a1c below seven and we're gon na need to closely monitor your blood sugars since we're going to be doing some medication therapy with antibiotics and and potentially some other medications any other questions comments or concerns before i have the nurse come in we're gon na prep you for that procedure
2,182
doctor: correct patient: if i heard
D2N086
8
[ "Chitchat" ]
[ "Null" ]
correct
2,183
doctor: yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy patient: okay sounds good
D2N086
9
[ "Discussion", "Medication" ]
[ "Plan" ]
yep that's correct so what we're gon na do is you said you're six days in do a ten or twelve day course so we're gon na go ahead and continue your antibiotics therapy that your pcp put you on i do want to get the culture back and then we'll make the determination as far as additional or changing that antibiotic therapy
2,184
doctor: alright
D2N086
10
[ "Chitchat" ]
[ "Null" ]
doctor: alright
2,185
doctor: hi richard how are you the medical assistant told me that you have a tick bite is that what happened patient: i really do n't know where i got it but i i had i do get out in the woods and i do spend a lot of time out in the yard but yeah i've got a tick bite around my knee and and it's been it's been over a week and and just it just burns and just quite annoying
D2N087
0
[ "Acute Symptoms", "Greetings" ]
[ "Subjective" ]
hi richard how are you the medical assistant told me that you have a tick bite is that what happened
2,186
doctor: okay and have you had any fever or chills patient: i have not at this point it just feels warm on that spot
D2N087
1
[ "Acute Symptoms", "Vegetative History" ]
[ "Subjective" ]
okay and have you had any fever or chills
2,187
doctor: okay alright and have you noticed any other joint pain like in your elbows or shoulders or anything like that that since this started patient: nothing other than my typical arthritic pain
D2N087
2
[ "Acute Symptoms" ]
[ "Subjective" ]
okay alright and have you noticed any other joint pain like in your elbows or shoulders or anything like that that since this started
2,188
doctor: okay alright now you say that you like to go outside and and you're working in the yard now i i heard that you were a a hunter when was the last time you went hunting has hunting season started yet i do n't even know patient: well i i did go hunting not long ago couple of weeks ago
D2N087
3
[ "Other Socials" ]
[ "Subjective" ]
okay alright now you say that you like to go outside and and you're working in the yard now i i heard that you were a a hunter when was the last time you went hunting has hunting season started yet i do n't even know
2,189
doctor: okay did you did you patient: windle season is open well it it's actually on a on a a got the right word for it but it it's where they train dogs and things like that
D2N087
4
[ "Other Socials" ]
[ "Subjective" ]
okay did you did you
2,190
doctor: okay did you i did did did were you able to shoot anything did you bring anything home patient: well actually i yeah i shut several i had some grandchildren with me so i let them have what they wanted
D2N087
6
[ "Chitchat" ]
[ "Null" ]
okay did you i did did did were you able to shoot anything did you bring anything home
2,191
doctor: nice nice you know i i did hear i do n't know much about hunting but i did hear a hunting software joke the other day do you want to hear it patient: sure
D2N087
7
[ "Chitchat" ]
[ "Null" ]
nice nice you know i i did hear i do n't know much about hunting but i did hear a hunting software joke the other day do you want to hear it
2,192
doctor: so what software do hunters use for designing and hunting their pray patient: man i have no idea
D2N087
8
[ "Chitchat" ]
[ "Null" ]
so what software do hunters use for designing and hunting their pray
2,193
doctor: the adobee illustrator get it patient: do n't be
D2N087
9
[ "Chitchat" ]
[ "Null" ]
the adobee illustrator get it
2,194
doctor: anyway i die grass let's just get back to our visit here so about your line or about your tick bite so do you notice that it's hard for you to move your knee at all patient: not at this time no
D2N087
10
[ "Acute Symptoms" ]
[ "Subjective" ]
anyway i die grass let's just get back to our visit here so about your line or about your tick bite so do you notice that it's hard for you to move your knee at all
2,195
doctor: no and do you have any problems walking patient: no
D2N087
11
[ "Acute Symptoms" ]
[ "Subjective" ]
no and do you have any problems walking
2,196
doctor: no okay and have you ever had a tick bite before patient: i have when i was younger i used to get a lot of them because i spent a lot of time out of the woods never get into anesthesia takes you can get several bites out of that but this was just one
D2N087
12
[ "Personal History" ]
[ "Subjective" ]
no okay and have you ever had a tick bite before
2,197
doctor: okay alright and have you ever been diagnosed with what we call lyme disease before patient: i have not
D2N087
13
[ "Personal History" ]
[ "Subjective" ]
okay alright and have you ever been diagnosed with what we call lyme disease before
2,198
doctor: you have not patient: i would n't know so i would n't know what symptoms are
D2N087
14
[ "Personal History" ]
[ "Subjective" ]
you have not
2,199