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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 t... | 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 t... | 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 m... | 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... | 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 ... | 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 yo... | 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 fo... | 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 . ... | 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 g... | 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... | 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... | 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 notice... | 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 fi... | 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 ... | 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... | 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 ba... | 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 . an... | 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... | 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 sti... | 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 yoursel... | 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 ... | 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 ... | 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 r... | 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 |
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