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DATEXIS
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aci_bench_intent_annotated

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doctor: um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ? patient: uh , i think i probably wan na shy away from any therapy . my , my wife got me into meditation recently and , and , uh , i , i find that relaxing . so , i think i'd like to continue that , at least for a couple more months and see how it goes .
D2N090
20
[ "Discussion" ]
[ "Plan" ]
um , is that something that you wan na revisit , or do you wan na look into therapy , or do you think anything's needed right now ?
2,300
doctor: okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you- patient: mm-hmm .
D2N090
21
[ "Physical Examination" ]
[ "Objective" ]
okay . all right . that sounds good . all right . well , i know the nurse did a quick review of systems with you , when you-
2,301
doctor: . checked in . do you have any symptoms , any chest pain or shortness of breath ? patient: none whatsoever .
D2N090
22
[ "Vegetative History" ]
[ "Subjective" ]
. checked in . do you have any symptoms , any chest pain or shortness of breath ?
2,302
doctor: lightheadedness ? dizziness ? patient: no .
D2N090
23
[ "Vegetative History" ]
[ "Subjective" ]
lightheadedness ? dizziness ?
2,303
doctor: no ? okay . um , and i just wan na go ahead and do a quick physical exam . patient: mm-hmm .
D2N090
24
[ "Physical Examination" ]
[ "Objective" ]
no ? okay . um , and i just wan na go ahead and do a quick physical exam .
2,304
doctor: hey , dragon . show me the vital signs . so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be . patient: mm-hmm .
D2N090
25
[ "Physical Examination" ]
[ "Objective" ]
hey , dragon . show me the vital signs . so , looking here right now , your vital signs look great . you know , your pulse ox is great . your h- your blood pressure and heart rate are right where they should be .
2,305
doctor: so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ? patient: sure .
D2N090
26
[ "Physical Examination" ]
[ "Objective" ]
so , i'm gon na just check you out , and i'm gon na let you know what i find . okay ?
2,306
doctor: okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past . patient: mm-hmm .
D2N090
27
[ "Physical Examination" ]
[ "Objective" ]
okay . so , on your physical exam , everything looks really good . um , you do n't appear in any distress at this time . i do n't appreciate any carotid bruits . your heart , on your heart exam , i do hear that slight 2/6 systolic ejection murmur , but we heard that in the past .
2,307
doctor: your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ? patient: mm-hmm .
D2N090
28
[ "Physical Examination" ]
[ "Objective" ]
your lungs sound nice and clear , but i notice , you know , 1+ , uh , edema in your lower extremities . okay ?
2,308
doctor: um , so , let's go ahead . i wan na look at some of your results . okay ? patient: sure .
D2N090
29
[ "Physical Examination" ]
[ "Objective" ]
um , so , let's go ahead . i wan na look at some of your results . okay ?
2,309
doctor: hey , dragon . show me the glucose . so , right now , your blood sugar is about 162 . have you eaten before you came in here ? patient: i did not .
D2N090
30
[ "Lab Examination" ]
[ "Objective" ]
hey , dragon . show me the glucose . so , right now , your blood sugar is about 162 . have you eaten before you came in here ?
2,310
doctor: okay . all right . um , hey , dragon . show me the diabetes labs . okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high . patient: mm-hmm .
D2N090
31
[ "Lab Examination" ]
[ "Objective" ]
okay . all right . um , hey , dragon . show me the diabetes labs . okay . i'm looking at your diabetes labs . you know , your hemoglobin a1c is about 8 , and that's a , that's a little high .
2,311
doctor: so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated . patient: mm-hmm .
D2N090
32
[ "Lab Examination" ]
[ "Objective" ]
so , not only , you know , have your blood sugars , were they high that one day , they were , they've been a little elevated .
2,312
doctor: so , we'll talk about , you know , how to go ahead and , and fix that . okay ? so , let me talk a little bit about my assessment and my plan for you . patient: mm-hmm .
D2N090
33
[ "Discussion" ]
[ "Plan" ]
so , we'll talk about , you know , how to go ahead and , and fix that . okay ? so , let me talk a little bit about my assessment and my plan for you .
2,313
doctor: so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further . patient: mm-hmm .
D2N090
34
[ "Medication", "Acute Assessment" ]
[ "Assessment", "Plan" ]
so , for your first problem , this hyperglycemia , you know , i wan na go ahead and increase your lantus to 20 units at night . okay ? i want you to continue your monitor your blood sugar and let me know how they're running 'cause we might have to adjust that further .
2,314
doctor: okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , dragon . order a hemoglobin a1c . for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ? patient: mm-hmm .
D2N090
35
[ "Discussion", "Follow-up", "Diagnostic Testing" ]
[ "Plan" ]
okay ? um , and i wan na order another hemoglobin a1c in a couple months . hey , dragon . order a hemoglobin a1c . for your next problem , your depression , i think you're doing a great job with your current strategies with the meditation . we will hold off on medication or therapy at this time , and you know to call me if you need anything , right ?
2,315
doctor: okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications . patient: okay .
D2N090
36
[ "Referral", "Reassessment" ]
[ "Assessment", "Plan" ]
okay . and for your third problem , your kidney transplant , your kidney function looks stable . uh , i'm gon na just have you go back to dr. reyes , to manage all of your immunosuppression medications .
2,316
doctor: um , and then , he knows to reach out to me if he needs anything . okay ? patient: you got it .
D2N090
37
[ "Referral" ]
[ "Plan" ]
um , and then , he knows to reach out to me if he needs anything . okay ?
2,317
doctor: all right . well , the nurse will be in soon to check you out . okay ? patient: perfect .
D2N090
38
[ "Chitchat" ]
[ "Null" ]
all right . well , the nurse will be in soon to check you out . okay ?
2,318
doctor: hey , dragon . finalize the note .
D2N090
39
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon . finalize the note .
2,319
doctor: hi jerry , how are you doing ? patient: hi , good to see you .
D2N091
0
[ "Greetings" ]
[ "Subjective" ]
hi jerry , how are you doing ?
2,320
doctor: good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you . patient: sure .
D2N091
1
[ "Chitchat" ]
[ "Null" ]
good to see you as well . um , so i know that the nurse told you about dax . i'd like to tell dax about you .
2,321
doctor: jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sclerosis who presents for an annual exam . so jerry , what's been going on since the last time i saw you ? patient: uh , we have been traveling all over the country . it's been kind of a stressful summer . kinda adjusting to everything in the fall and so far it's been good , but ah , lack of sleep , it's been really getting to me .
D2N091
2
[ "Personal History" ]
[ "Subjective" ]
jerry is a 54 year old male with a past medical history , significant for osteoporosis and multiple sclerosis who presents for an annual exam . so jerry , what's been going on since the last time i saw you ?
2,322
doctor: okay . all right . and have you taken anything for the insomnia . have you tried any strategies for it . patient: i've tried everything from melatonin to meditation to , uh , t- stretching out every morning when i get up . nothing really seems to help though .
D2N091
3
[ "Therapeutic History" ]
[ "Subjective" ]
okay . all right . and have you taken anything for the insomnia . have you tried any strategies for it .
2,323
doctor: okay . all right . in terms of your osteoporosis , i know we have you on fosamax , any issues with your joints , any issues like- patient: no .
D2N091
4
[ "Personal History" ]
[ "Subjective" ]
okay . all right . in terms of your osteoporosis , i know we have you on fosamax , any issues with your joints , any issues like-
2,324
doctor: no broken bones recently ? patient: no .
D2N091
5
[ "Personal History" ]
[ "Subjective" ]
no broken bones recently ?
2,325
doctor: no , nothing like that ? patient: no .
D2N091
6
[ "Personal History" ]
[ "Subjective" ]
no , nothing like that ?
2,326
doctor: okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ? patient: uh , about six months ago .
D2N091
7
[ "Personal History" ]
[ "Subjective" ]
okay . and then in terms of your multiple sclerosis , when was the last time you saw the neurologist ?
2,327
doctor: okay and you're taking the medication ? patient: yes .
D2N091
8
[ "Therapeutic History" ]
[ "Subjective" ]
okay and you're taking the medication ?
2,328
doctor: okay . and any issues with that ? patient: none whatsoever .
D2N091
9
[ "Therapeutic History" ]
[ "Subjective" ]
okay . and any issues with that ?
2,329
doctor: and any additional weakness ? i know you were having some issues with your right leg , but that seems to have improved or ? patient: yes a lingering issue with my knee surgery . but other than that it's been fine .
D2N091
10
[ "Personal History" ]
[ "Subjective" ]
and any additional weakness ? i know you were having some issues with your right leg , but that seems to have improved or ?
2,330
doctor: okay . all right , well i know you did a review of systems sheet when you checked in . patient: mm-hmm .
D2N091
12
[ "Physical Examination" ]
[ "Objective" ]
okay . all right , well i know you did a review of systems sheet when you checked in .
2,331
doctor: and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ? patient: no .
D2N091
13
[ "Vegetative History" ]
[ "Subjective" ]
and you were endorsing that insomnia . any other issues , chest pain , shortness of breath , anything ?
2,332
doctor: all right . well lets go ahead and do a quick physical exam . patient: mm-hmm .
D2N091
14
[ "Physical Examination" ]
[ "Objective" ]
all right . well lets go ahead and do a quick physical exam .
2,333
doctor: hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find . patient: sure .
D2N091
15
[ "Physical Examination" ]
[ "Objective" ]
hey dragon , show me the vital signs . so your vital signs here in the office they look really good . i'm just going to listen to your heart and lungs and let you know what i find .
2,334
doctor: okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee . patient: mm-hmm .
D2N091
16
[ "Physical Examination" ]
[ "Objective" ]
okay . on physical examination everything looks good . you know your lungs are nice and clear . your heart sounds good . you know you do have some weakness of your lower extremities . the right is about 4 out of 5 , the left is about 3 out of 5 . but you reflexes are really good so i'm , i'm encouraged by that . and you do have some , you know , arthritic changes of the right knee .
2,335
doctor: um , so let's go over some of your results , okay ? patient: sure .
D2N091
17
[ "Chitchat" ]
[ "Null" ]
um , so let's go over some of your results , okay ?
2,336
doctor: hey dragon , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . do you need a refill on that ? patient: actually i do .
D2N091
18
[ "Discussion", "Medication", "Radiology Examination", "Reassessment" ]
[ "Objective", "Assessment", "Plan" ]
hey dragon , show me the right knee x-ray . and here's the x-ray of your right knee , which shows some changes from arthritis , but otherwise that looks good . so let's talk a little bit about my assessment and plan . from an osteoporosis standpoint , we'll go ahead and order , you know , re- continue on the fosamax . do you need a refill on that ?
2,337
doctor: hey dragon , order a refill of fosamax 1 tab per week , 11 refills . and then in t- , for your second problem , your multiple sclerosis i want you to go ahead and continue to see the neurologist and continue on those medications . and let me know if you need anything from that standpoint , okay ? patient: you got it .
D2N091
19
[ "Discussion", "Referral", "Medication", "Reassessment" ]
[ "Assessment", "Plan" ]
hey dragon , order a refill of fosamax 1 tab per week , 11 refills . and then in t- , for your second problem , your multiple sclerosis i want you to go ahead and continue to see the neurologist and continue on those medications . and let me know if you need anything from that standpoint , okay ?
2,338
doctor: any questions ? patient: not at this point , no .
D2N091
20
[ "Discussion" ]
[ "Plan" ]
any questions ?
2,339
doctor: okay , great . hey dragon , finalize the note .
D2N091
21
[ "Chitchat" ]
[ "Null" ]
doctor: okay , great . hey dragon , finalize the note .
2,340
doctor: hello , mrs . martinez . good to see you today . patient: hey , dr . gomez .
D2N092
0
[ "Greetings" ]
[ "Subjective" ]
hello , mrs . martinez . good to see you today .
2,341
doctor: hey , dragon , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ? patient: um , my arm hurts right here . kind of toward my wrist . this part of my arm .
D2N092
1
[ "Acute Symptoms" ]
[ "Subjective" ]
hey , dragon , i'm here seeing mrs . martinez . she's a 43-year-old female . why are we seeing you today ?
2,342
doctor: so you have pain in your distal radius ? patient: yes .
D2N092
2
[ "Acute Symptoms" ]
[ "Subjective" ]
so you have pain in your distal radius ?
2,343
doctor: how did that happen ? patient: um , i was playing tennis , and when i went to hit , um , i was given a , a backhand , and when i did , i m- totally missed the ball , hit the top of the net but the pole part . and , and it just jarred my arm .
D2N092
3
[ "Acute Symptoms" ]
[ "Subjective" ]
how did that happen ?
2,344
doctor: okay . and did it swell up at all ? or- patient: it did . it got a ... it had a little bit of swelling . not a lot .
D2N092
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and did it swell up at all ? or-
2,345
doctor: okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ? patient: a little bit when i move my wrist . um , no numbness in my hand .
D2N092
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and , um , did , uh , do you have any numbness in your hand at all ? or any pain when you move your wrist ?
2,346
doctor: okay . do you have any past medical history of anything ? patient: um , yes . allergic , um , l- i have allergies . and so i take flonase .
D2N092
6
[ "Personal History" ]
[ "Subjective" ]
okay . do you have any past medical history of anything ?
2,347
doctor: okay . and any surgeries in the past ? patient: yes . i actually had a trauma of , um , a stabbing of , um ... i actually fell doing lawn work-
D2N092
7
[ "Personal History" ]
[ "Subjective" ]
okay . and any surgeries in the past ?
2,348
doctor: i was wondering where you were going to go with that . patient: yeah .
D2N092
10
[ "Chitchat" ]
[ "Null" ]
i was wondering where you were going to go with that .
2,349
doctor: okay . great . so , let's take a look at , uh , the x-ray of your arm . hey dragon , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you . patient: okay .
D2N092
11
[ "Radiology Examination" ]
[ "Objective" ]
okay . great . so , let's take a look at , uh , the x-ray of your arm . hey dragon , let's see the x-ray . okay , looking at your x-ray , i do n't see any fractures , uh , do n't really see any abnormalities at all . it looks essentially normal . great . let me examine you .
2,350
doctor: does it hurt when i press on your arm here ? patient: yes .
D2N092
12
[ "Physical Examination" ]
[ "Objective" ]
does it hurt when i press on your arm here ?
2,351
doctor: okay . how about when i bend your arm ? patient: yes .
D2N092
13
[ "Physical Examination" ]
[ "Objective" ]
okay . how about when i bend your arm ?
2,352
doctor: okay . that's pretty tender , ? patient: mm-hmm .
D2N092
14
[ "Physical Examination" ]
[ "Objective" ]
okay . that's pretty tender , ?
2,353
doctor: how about when i go backwards like that ? patient: not as much .
D2N092
15
[ "Physical Examination" ]
[ "Objective" ]
how about when i go backwards like that ?
2,354
doctor: and how about when i flex like this ? patient: a little .
D2N092
16
[ "Physical Examination" ]
[ "Objective" ]
and how about when i flex like this ?
2,355
doctor: but mostly when i do that type of motion ? patient: yes .
D2N092
17
[ "Physical Examination" ]
[ "Objective" ]
but mostly when i do that type of motion ?
2,356
doctor: okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again . patient: okay .
D2N092
18
[ "Follow-up", "Medication", "Acute Assessment" ]
[ "Assessment", "Plan" ]
okay , great . so , um , you have pain following hitting your arm on the net . on your exam , you definitely have some tenderness over your distal radius , um , on your arm . you have pain when i stress especially your thumb , and , and flex your thumb . so , i think what you have is basically just a strain and maybe a contusion to that muscle , from hitting it . um , you certainly do n't have a fracture . i think at this point , we're really going to treat it actually conservatively . we'll have you use ice , um , uh , for the , the pain and swelling . and some anti inflammatory . um , what we'll do is give you some motrin , 800 milligrams three times a day , with food . um , if it does n't get any better in the next week or so , let me know , and we'll take a look at you again .
2,357
doctor: okay , great . hey dragon , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . dragon you can finalize the note . patient: thank you .
D2N092
19
[ "Chitchat" ]
[ "Plan" ]
okay , great . hey dragon , go ahead and order the procedures , and the medications as discussed . why do n't you come with me . dragon you can finalize the note .
2,358
doctor: hey lawrence . how are you ? patient: hey , good to see you .
D2N093
0
[ "Greetings" ]
[ "Subjective" ]
hey lawrence . how are you ?
2,359
doctor: it's good to see you too . so , i know the nurse told you about dax . patient: mm-hmm .
D2N093
1
[ "Chitchat" ]
[ "Null" ]
it's good to see you too . so , i know the nurse told you about dax .
2,360
doctor: i'd like to tell dax a little bit about you . patient: sure .
D2N093
2
[ "Chitchat" ]
[ "Null" ]
i'd like to tell dax a little bit about you .
2,361
doctor: so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ? patient: uh , i , i've noticed that i've been swelling up a little bit . i think a lot of it has to do with going to some house parties , eating some salty foods . i feel really lethargic .
D2N093
3
[ "Acute Symptoms", "Personal History" ]
[ "Subjective" ]
so , lawrence is a 62-year-old male , with a past medical history significant for type i diabetes , congestive heart failure , depression , and reflux , who presents with complaints of shortness of breath . so lawrence , what's been going on ? wh- what's wrong with your breathing ?
2,362
doctor: okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ? patient: it's something like walking up a flight of stairs i'll actually feel it .
D2N093
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . and when you get short of breath , are you short of breath when you're just sitting here ? do you feel short of breath when you're walking ?
2,363
doctor: okay . all right . now , um , how long has this been going on for ? patient: probably about 10 days .
D2N093
5
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . all right . now , um , how long has this been going on for ?
2,364
doctor: okay . all right . and you said you're noticed some swelling in your legs ? patient: a little bit .
D2N093
6
[ "Vegetative History" ]
[ "Subjective" ]
okay . all right . and you said you're noticed some swelling in your legs ?
2,365
doctor: okay . do you have problems lying flat in bed ? patient: um , i'm a little uncomfortable when i wake up in the morning and i feel pretty stiff . and , and , like , it takes me a little while to adjust to walking when i get up .
D2N093
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . do you have problems lying flat in bed ?
2,366
doctor: okay . all right . do you ever wake up acutely short of breath at night ? patient: um , it happened once , probably about a week ago , but it has n't happened since . so i have n't been that concerned about it .
D2N093
8
[ "Vegetative History" ]
[ "Subjective" ]
okay . all right . do you ever wake up acutely short of breath at night ?
2,367
doctor: okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump . patient: mm-hmm .
D2N093
9
[ "Personal History" ]
[ "Subjective" ]
okay . all right . in terms of your , your diabetes , how are you doing with that ? i know you're on the insulin pump .
2,368
doctor: um , are your blood sugars okay ? have you noticed a spike in them recently ? patient: um , i have n't . i've been pretty good about monitoring it so i ... during the working week , i stay on top of that . but on saturdays or sundays we're so busy i forget to monitor it . but i have n't seen anything spike .
D2N093
10
[ "Vegetative History" ]
[ "Subjective" ]
um , are your blood sugars okay ? have you noticed a spike in them recently ?
2,369
doctor: okay . and i remember your affinity for chocolate bars , so ... patient: guilty as charged . i love chocolate bars .
D2N093
11
[ "Vegetative History" ]
[ "Subjective" ]
okay . and i remember your affinity for chocolate bars , so ...
2,370
doctor: okay . all right . so , in terms of your depression , how are you doing with that ? patient: uh , it's been a crazy year and a half . um , i've tried some natural solutions . in the summer i did stretches outdoors every morning , which was great , but now the weather changed and , uh , you know , i've got ta find some alternatives . i'm not ready to try any medications just yet , so-
D2N093
12
[ "Personal History" ]
[ "Subjective" ]
okay . all right . so , in terms of your depression , how are you doing with that ?
2,371
doctor: okay . we'll talk about that . patient: sure .
D2N093
14
[ "Personal History" ]
[ "Subjective" ]
okay . we'll talk about that .
2,372
doctor: and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole . patient: mm-hmm .
D2N093
15
[ "Personal History", "Therapeutic History" ]
[ "Subjective" ]
and then in terms of your reflux , how are you doing ? i know we had you on the omeprazole .
2,373
doctor: you were making some lifestyle modifications , cutting back on your red bull and caffeine . patient: yeah .
D2N093
16
[ "Personal History" ]
[ "Subjective" ]
you were making some lifestyle modifications , cutting back on your red bull and caffeine .
2,374
doctor: alcohol intake has been ... how's that been ? patient: tough during the holiday season , but i'm , i'm better .
D2N093
17
[ "Drug History" ]
[ "Subjective" ]
alcohol intake has been ... how's that been ?
2,375
doctor: okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ? patient: no . no . absolutely not .
D2N093
18
[ "Personal History" ]
[ "Subjective" ]
okay . all right . and no issues with your depression ? you do n't want to hurt yourself or anyone else ?
2,376
doctor: okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath . patient: mm-hmm .
D2N093
19
[ "Physical Examination" ]
[ "Objective" ]
okay , all right . well , let's go ahead . i know you did a review of system sheet when you checked in and you endorsed the shortness of breath .
2,377
doctor: any other symptoms ? chest pain , fever , chills , cough ? patient: no .
D2N093
20
[ "Vegetative History" ]
[ "Subjective" ]
any other symptoms ? chest pain , fever , chills , cough ?
2,378
doctor: um , belly pain ? patient: no .
D2N093
21
[ "Vegetative History" ]
[ "Subjective" ]
um , belly pain ?
2,379
doctor: okay . let's go ahead . i want to move on to a physical exam . patient: mm-hmm .
D2N093
22
[ "Physical Examination" ]
[ "Objective" ]
okay . let's go ahead . i want to move on to a physical exam .
2,380
doctor: hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find . patient: mm-hmm .
D2N093
23
[ "Physical Examination" ]
[ "Objective" ]
hey , dragon ? show me the vital signs . so here in the office , you know , your vital signs look good . your , your pulse ox ... that's your oxygenation level ... looks good . so i'm encouraged by that with you just sitting here , okay ? i'm gon na go ahead and do another , uh , just check you over . i'll let you know what i find .
2,381
doctor: okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion . patient: mm-hmm .
D2N093
24
[ "Physical Examination" ]
[ "Objective" ]
okay . all right . so , on your exam things look okay . so , i do n't appreciate any jugular venous distension or any carotid bruits on your neck exam . on your heart exam , i do appreciate a slight 3 out of 6 systolic ejection murmur . on your lung exam , i do appreciate some crackles , bilaterally , at the bases . and on your lower extremity exam i do appreciate 1+ pitting edema . so what does all that mean ? so , i do think that you're retaining some fluid . it's probably from some of the dietary indiscretion .
2,382
doctor: but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ? patient: okay .
D2N093
25
[ "Radiology Examination" ]
[ "Objective" ]
but i wan na go ahead and look at some of the results , okay ? i had the nurse do a chest x-ray on you before we came in , okay ? hey , dragon ? show me the test x-ray . so i reviewed the results of your chest x-ray and it looks good . there's no e- evidence of any airspace disease , but that does n't mean that you still ca n't be retaining some fluid , okay ?
2,383
doctor: hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good . patient: mm-hmm .
D2N093
26
[ "Lab Examination" ]
[ "Objective" ]
hey , dragon ? show me the labs . and your labs look okay . you know , you do n't have an elevated white blood cell count so i'm not really concerned about infection . we saw the chest x-ray , there's no pneumonia , so that's good .
2,384
doctor: so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every day . patient: mm-hmm .
D2N093
27
[ "Medication", "Other Treatments", "Acute Assessment" ]
[ "Assessment", "Plan" ]
so , let's talk a little bit about , you know , my assessment and my plan for you . okay ? so , for your first problem of your shortness of breath i think that you are in an acute heart failure exacerbation . i want to go ahead and , uh , put you on some lasix , 40 milligrams a day . i want you to weigh yourself every day .
2,385
doctor: if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911- patient: mm-hmm .
D2N093
28
[ "Discussion", "Follow-up" ]
[ "Plan" ]
if your weight is n't going down , uh , or if it's going up i want you to call me . certainly , if you get more short of breath at rest i want you to go ahead and call me or call 911-
2,386
doctor: . and go into the emergency room . you might need some intravenous diuretics . patient: mm-hmm .
D2N093
29
[ "Discussion" ]
[ "Plan" ]
. and go into the emergency room . you might need some intravenous diuretics .
2,387
doctor: okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ? patient: sure .
D2N093
30
[ "Discussion", "Follow-up", "Referral", "Diagnostic Testing", "Reassessment" ]
[ "Assessment", "Plan" ]
okay ? for your second problem of your type i diabetes , um , let's go ahead ... i wan na order a hemoglobin a1c for , um , uh , just in a , like a month or so , just to see if we have to make any adjustments . and i want you to follow up with your endocrinologist . okay ? and i also want to make sure that you have a recent eye exam . all right ? uh , for your third problem of your depression , let's go ahead and refer you to psychiatry , just for some , um , like , talk therapy to help you through that . okay ?
2,388
doctor: no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ? patient: not at this point .
D2N093
31
[ "Discussion", "Medication" ]
[ "Plan" ]
no medications . and for your fourth problem of your reflux , let's go ahead and continue you on the omeprazole , 20 milligrams a day . do you have any questions , lawrence ?
2,389
doctor: okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ? patient: you got it .
D2N093
32
[ "Discussion", "Follow-up" ]
[ "Plan" ]
okay . um , uh , again , i want you to call me if you have any problems with your breathing , okay ?
2,390
doctor: hey , dragon ? finalize the notes ...
D2N093
33
[ "Chitchat" ]
[ "Null" ]
doctor: hey , dragon ? finalize the notes ...
2,391
doctor: hey , ms. james . nice to meet you . patient: nice to meet you , dr. cooper . how are you ?
D2N094
0
[ "Greetings" ]
[ "Subjective" ]
hey , ms. james . nice to meet you .
2,392
doctor: i'm well . hey , dragon , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ? patient: i hurt my , uh , finger when i was skiing this past weekend .
D2N094
1
[ "Acute Symptoms" ]
[ "Subjective" ]
i'm well . hey , dragon , i'm seeing ms. james . she's a 42-year-old female , and what brings you in today ?
2,393
doctor: really ? patient: yeah . yeah , so , um , i was going down hill , double diamonds , uh , double black diamonds , and i just lost control , and i , you know , flipped down a few ways , but , uh , somewhere along the way , i , i jammed my , my index finger on something . i'm not sure what .
D2N094
2
[ "Acute Symptoms" ]
[ "Subjective" ]
really ?
2,394
doctor: okay . so this happened last saturday , you said ? patient: it was saturday , yes .
D2N094
3
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . so this happened last saturday , you said ?
2,395
doctor: okay . so about five days of this right index finger pain . patient: mm-hmm .
D2N094
4
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . so about five days of this right index finger pain .
2,396
doctor: have you taken any medicine for it ? patient: i took some ibuprofen . um , did n't really seem to help .
D2N094
5
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
have you taken any medicine for it ?
2,397
doctor: okay . have you iced it or put a splint on it ? patient: no .
D2N094
6
[ "Acute Symptoms", "Therapeutic History" ]
[ "Subjective" ]
okay . have you iced it or put a splint on it ?
2,398
doctor: okay . and what would you rate your pain ? patient: it's about a seven .
D2N094
7
[ "Acute Symptoms" ]
[ "Subjective" ]
okay . and what would you rate your pain ?
2,399