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doctor: okay , great . so we will complete that today , um , to assess your overall cardiac structure and function , as well as , uh , the valve view of where diseased . patient: okay . | D2N105 | 36 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | okay , great . so we will complete that today , um , to assess your overall cardiac structure and function , as well as , uh , the valve view of where diseased . | 2,700 |
doctor: and some hospital outcomes and what we might suggest to fix that out , i'll go over that . so one possible suspicion i'm having is it's called , um , aortic stenosis , and that just means that one of your main valves of your heart has narrowed a bit and the valve does n't really open , um , quite fully . and th... | D2N105 | 37 | [
"Discussion",
"Acute Assessment"
] | [
"Assessment",
"Plan"
] | and some hospital outcomes and what we might suggest to fix that out , i'll go over that . so one possible suspicion i'm having is it's called , um , aortic stenosis , and that just means that one of your main valves of your heart has narrowed a bit and the valve does n't really open , um , quite fully . and this could... | 2,701 |
doctor: and if this is severe , then we might wan na perform a procedure called the transcatheter aortic valve replacement , or we just call it tavr . and it is a minimally invasive procedure to replace the valve . patient: well , i would have to think about that . i'm not too sure i'd wan na do that , given my age of ... | D2N105 | 38 | [
"Discussion",
"Other Treatments"
] | [
"Plan"
] | and if this is severe , then we might wan na perform a procedure called the transcatheter aortic valve replacement , or we just call it tavr . and it is a minimally invasive procedure to replace the valve . | 2,702 |
doctor: yeah , sure , no problem . and we do n't have to make any decisions today , just , you know , wanted to go over a couple of these things . um , but sometimes we can also perform a surgical aortic valve replacement , or it's called an savr . but really , because of your age and medical history , um , unfortunate... | D2N105 | 39 | [
"Discussion",
"Other Treatments"
] | [
"Plan"
] | yeah , sure , no problem . and we do n't have to make any decisions today , just , you know , wanted to go over a couple of these things . um , but sometimes we can also perform a surgical aortic valve replacement , or it's called an savr . but really , because of your age and medical history , um , unfortunately , tha... | 2,703 |
doctor: yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently . patient: okay , good . | D2N105 | 40 | [
"Discussion",
"Medication"
] | [
"Plan"
] | yeah , agreed . okay . and , um , so couple other things real quick . so it looked like your blood pressure looked really good today . so we're not going to change your amlodipine or lisinopril . so just continue taking those as you are currently . | 2,704 |
doctor: and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able ... | D2N105 | 41 | [
"Discussion",
"Medication"
] | [
"Plan"
] | and then , it also looks like you're taking about 20 milligrams of simvastatin for your lipids . and i will pr- , um , defer to your pcp . however , given you are having leg pain in both your legs , and given your age and no history of coronary artery d- , artery disease , it is possible that you might be able to stop ... | 2,705 |
doctor: yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin . patient: okay , that sounds great . thank you . | D2N105 | 42 | [
"Discussion"
] | [
"Plan"
] | yeah , um , possibly . he would have to evaluate you , but it is certainly something to discuss with him . so i will send over the results of the echocardiogram and also my recommendations and then you guys can talk about the statin . | 2,706 |
doctor: you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them . patient: okay , i will . | D2N105 | 43 | [
"Medication",
"Reassessment"
] | [
"Assessment",
"Plan"
] | you're welcome . and then , um , lastly , your hyperthyroidism , uh , i see you're taking levothyroxine . and again , no change here and you can just keep taking that as you have them . | 2,707 |
doctor: all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ? patient: not that i can think of . thank you so much . and i think it looks good . | D2N105 | 44 | [
"Discussion",
"Follow-up",
"Diagnostic Testing"
] | [
"Plan"
] | all right . so we will see you back here in about three or four weeks to discuss the results and your next steps . um , and we'll , uh , take care of your echocardiogram today . um , any questions ? | 2,708 |
doctor: okay , awesome . all right . well , have a good rest of your day , and we'll see you soon . for physical exam , constitutional elderly otherwise no acute distress . cardiovascular normal s1 and s2 is preserved with a normal rate and regular rhythm . there is a 4/6 systolic murmur at the right upper sternal bord... | D2N105 | 45 | [
"Physical Examination",
"Acute Assessment",
"Reassessment",
"Diagnostic Testing",
"Follow-up",
"Therapeutic History"
] | [
"Subjective",
"Objective",
"Assessment",
"Plan"
] | doctor: okay , awesome . all right . well , have a good rest of your day , and we'll see you soon . for physical exam , constitutional elderly otherwise no acute distress . cardiovascular normal s1 and s2 is preserved with a normal rate and regular rhythm . there is a 4/6 systolic murmur at the right upper sternal bord... | 2,709 |
doctor: hey charles i'm using this cool new recording device to help me with my documentation is that okay with you patient: sure | D2N106 | 0 | [
"Greetings"
] | [
"Subjective"
] | hey charles i'm using this cool new recording device to help me with my documentation is that okay with you | 2,710 |
doctor: awesome how are you doing today patient: well i could be better you know i moved out in the city about two years ago bought this big plot of land | D2N106 | 1 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | awesome how are you doing today | 2,711 |
doctor: awesome. you be hunter patient: huge hunter i love hunter | D2N106 | 3 | [
"Other Socials"
] | [
"Subjective"
] | awesome. you be hunter | 2,712 |
doctor: you want to carry share sure yeah we can switch patient: nice but so the thing is i have noticed that for some reason my breathing is n't what it used to be | D2N106 | 6 | [
"Chitchat"
] | [
"Null"
] | you want to carry share sure yeah we can switch | 2,713 |
doctor: you look pretty healthy patient: thanks so do you | D2N106 | 8 | [
"Acute Symptoms"
] | [
"Subjective"
] | you look pretty healthy | 2,714 |
doctor: thank you you you're feeling short of breath patient: yes | D2N106 | 9 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | thank you you you're feeling short of breath | 2,715 |
doctor: okay is there you know is there any other symptoms that you have with that patient: i get like you know mid shortness of breath suddenly for some reason i'm not quite sure why | D2N106 | 10 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | okay is there you know is there any other symptoms that you have with that | 2,716 |
doctor: mm-hmm patient: i always think it's allergies | D2N106 | 12 | [
"Acute Symptoms",
"Vegetative History"
] | [
"Subjective"
] | mm-hmm | 2,717 |
doctor: i have a dog that eyes water like that she always gets eyebugers patient: yeah i get eyebugers too | D2N106 | 14 | [
"Chitchat"
] | [
"Null"
] | i have a dog that eyes water like that she always gets eyebugers | 2,718 |
doctor: okay great do you ever notice a rash with any of this patient: no | D2N106 | 16 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay great do you ever notice a rash with any of this | 2,719 |
doctor: do you have any nausea vomiting patient: no | D2N106 | 17 | [
"Vegetative History"
] | [
"Subjective"
] | do you have any nausea vomiting | 2,720 |
doctor: besides when you go out heavy drinking right patient: i mean i diarrhea quite a bit once i go out | D2N106 | 18 | [
"Drug History",
"Vegetative History"
] | [
"Subjective"
] | besides when you go out heavy drinking right | 2,721 |
doctor: i understand that patient: heavy drinking | D2N106 | 19 | [
"Drug History",
"Vegetative History"
] | [
"Subjective"
] | i understand that | 2,722 |
doctor: yeah do you ever get lip or throat swelling patient: no | D2N106 | 20 | [
"Personal History"
] | [
"Subjective"
] | yeah do you ever get lip or throat swelling | 2,723 |
doctor: have you ever had any issues with allergies in the past patient: no | D2N106 | 21 | [
"Personal History"
] | [
"Subjective"
] | have you ever had any issues with allergies in the past | 2,724 |
doctor: hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house patient: i have noticed them in all three situations | D2N106 | 22 | [
"Personal History"
] | [
"Subjective"
] | hmmm what situations do you notice the symptoms come on when is it when you're near your cat or outside the house | 2,725 |
doctor: hmmm yeah i'm not a big cat person patient: no neither | D2N106 | 24 | [
"Chitchat"
] | [
"Null"
] | hmmm yeah i'm not a big cat person | 2,726 |
doctor: do you do you have any symptoms now well which is patient: no | D2N106 | 25 | [
"Acute Symptoms"
] | [
"Subjective"
] | do you do you have any symptoms now well which is | 2,727 |
doctor: mm-hmm patient: okay | D2N106 | 27 | [
"Chitchat"
] | [
"Null"
] | mm-hmm | 2,728 |
doctor: okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on you... | D2N106 | 28 | [
"Physical Examination",
"Acute Assessment",
"Radiology Examination",
"Medication"
] | [
"Objective",
"Assessment",
"Plan"
] | okay alright so i'm gon na do a physical exam for you right now your vital signs look good your pulse is okay and yeah your pulse ox is normal so that's good you do n't appear in any distress you may be might be a little bit nervous to come in and see me but looks pretty good i do not appreciate any rash on your body t... | 2,729 |
doctor: you take that once daily and that's gon na help decrease the occurrences of your asthma patient: hmmm | D2N106 | 29 | [
"Discussion",
"Medication"
] | [
"Plan"
] | you take that once daily and that's gon na help decrease the occurrences of your asthma | 2,730 |
doctor: i also am gon na proceed with allergy testing have you ever had an allergy test before patient: no | D2N106 | 30 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | i also am gon na proceed with allergy testing have you ever had an allergy test before | 2,731 |
doctor: okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next ... | D2N106 | 31 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | okay we'll start with skin testing and we'll see if we can target what the triggers in hopes in hopes that we can avoid any any other management and this can be successful if we ca n't figure out what it is from that we'll have to discuss more testing in your blood and do immunotherapy so i wan na see you next week to ... | 2,732 |
doctor: so bryan it's nice to see you again in the office today what's going on patient: i was in my yard yesterday and i was raking leaves and i felt fine and then when i got into my house about two hours later my back started tightening up and i started getting pins and needles in my right foot | D2N107 | 0 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | so bryan it's nice to see you again in the office today what's going on | 2,733 |
doctor: alright have you ever had this type of back pain before patient: i had it once about three years ago but it went away after a day | D2N107 | 1 | [
"Personal History"
] | [
"Subjective"
] | alright have you ever had this type of back pain before | 2,734 |
doctor: okay and did you try anything for the pain yet did you take anything or have you have you tried icing patient: put some ice on it and i tried two advils and it did n't help | D2N107 | 2 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay and did you try anything for the pain yet did you take anything or have you have you tried icing | 2,735 |
doctor: okay does it get better when you're laying down sitting standing patient: yeah i think the only thing that helped was a hot shower and it feels a little better when i sit | D2N107 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay does it get better when you're laying down sitting standing | 2,736 |
doctor: okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately patient: i i i normally do n't do any physical activity | D2N107 | 4 | [
"Other Socials"
] | [
"Subjective"
] | okay alright so you said you were raking leaves and now it's been kind of that weather outside for cleaning out the yard have you been doing a lot of yard work lately | 2,737 |
doctor: yeah i hear you i make a i make my husband do all the yard work too so alright let me take a look at that low back if if you bend over does that hurt patient: it hurts a little bit when i bend over yes | D2N107 | 5 | [
"Physical Examination"
] | [
"Objective"
] | yeah i hear you i make a i make my husband do all the yard work too so alright let me take a look at that low back if if you bend over does that hurt | 2,738 |
doctor: okay how about when you stand back up patient: no pain | D2N107 | 6 | [
"Physical Examination"
] | [
"Objective"
] | okay how about when you stand back up | 2,739 |
doctor: okay so no pain on extension some pain on flexion how about when i push right here on your back patient: yeah that hurts | D2N107 | 7 | [
"Physical Examination"
] | [
"Objective"
] | okay so no pain on extension some pain on flexion how about when i push right here on your back | 2,740 |
doctor: okay so some pain to palpation right around the l5 can i have that patient: what happens when family members chime in like i'm doing right now because i actually think it was it hurts more when he stands up because i've watched him bend over but it's when he stands up that it really hurts | D2N107 | 8 | [
"Physical Examination"
] | [
"Objective"
] | okay so some pain to palpation right around the l5 can i have that | 2,741 |
doctor: okay and and what's your relationship patient: partners | D2N107 | 9 | [
"Other Socials"
] | [
"Subjective"
] | okay and and what's your relationship | 2,742 |
doctor: okay so your partner is here with you today and reports that he is also having pain when you are standing up patient: i've spent so many times you know who i am | D2N107 | 10 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay so your partner is here with you today and reports that he is also having pain when you are standing up | 2,743 |
doctor: so that's right you always come in together have you noticed anything else partner when when he is patient: i'm worried about it because he is you know his pain tolerance is so high and he would n't be saying anything if it really was n't a problem because it's not at all like last week when he thought about ra... | D2N107 | 11 | [
"Personal History"
] | [
"Subjective"
] | so that's right you always come in together have you noticed anything else partner when when he is | 2,744 |
doctor: okay so you think this is more of a long term injury patient: no he was just thinking about it hurting when he thought about raking but it did n't | D2N107 | 12 | [
"Personal History"
] | [
"Subjective"
] | okay so you think this is more of a long term injury | 2,745 |
doctor: okay alright and have you noticed any any prior pain with with the back patient: i do n't want to take this away you better go back to talking to him | D2N107 | 13 | [
"Personal History"
] | [
"Subjective"
] | okay alright and have you noticed any any prior pain with with the back | 2,746 |
doctor: that's alright let's see how it turns out okay so how about if you if i push down on both your feet like this can you push back up on my hands patient: can you repeat that | D2N107 | 14 | [
"Physical Examination"
] | [
"Objective"
] | that's alright let's see how it turns out okay so how about if you if i push down on both your feet like this can you push back up on my hands | 2,747 |
doctor: if i'm pushing down on your feet can you push push your feet back patient: i | D2N107 | 15 | [
"Physical Examination"
] | [
"Objective"
] | if i'm pushing down on your feet can you push push your feet back | 2,748 |
doctor: alright so your dorsiflexion is normal looks like pulses are equal in all extremities you said you had a little bit of a tingling sensation in which leg patient: that would be my right leg | D2N107 | 16 | [
"Physical Examination"
] | [
"Objective"
] | alright so your dorsiflexion is normal looks like pulses are equal in all extremities you said you had a little bit of a tingling sensation in which leg | 2,749 |
doctor: okay so some tingling in your right leg alright so i know that you had an x-ray when you came in because we always do x-rays when we have our patients come in of your low back and everything looks normal from that perspective so for your back pain sounds like you probably sprained your low back so i what i want... | D2N107 | 17 | [
"Discussion",
"Medication",
"Radiology Examination",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | okay so some tingling in your right leg alright so i know that you had an x-ray when you came in because we always do x-rays when we have our patients come in of your low back and everything looks normal from that perspective so for your back pain sounds like you probably sprained your low back so i what i want you to ... | 2,750 |
doctor: alright so i'll prescribe that i'm also gon na prescribe some physical therapy i know you said you have n't been overly active and your partner reported the same thing for a long time so we might wan na get you into some pt and hopefully get you back back in shape get you some stretches that you can do and some... | D2N107 | 18 | [
"Discussion",
"Medication",
"Referral"
] | [
"Plan"
] | alright so i'll prescribe that i'm also gon na prescribe some physical therapy i know you said you have n't been overly active and your partner reported the same thing for a long time so we might wan na get you into some pt and hopefully get you back back in shape get you some stretches that you can do and some exercis... | 2,751 |
doctor: alright patient: i think he should have an mri now i think he had surgery yesterday i think he should have an mri now this it's been hurting for like six hours now and she had an mri we are really worried about it | D2N107 | 19 | [
"Discussion"
] | [
"Plan"
] | alright | 2,752 |
doctor: alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving patient: good answer | D2N107 | 20 | [
"Follow-up",
"Diagnostic Testing"
] | [
"Plan"
] | alright you know let's give it a couple of weeks and let's give it two weeks and then call me back and we'll get you an mri if it's still not improving | 2,753 |
doctor: alright alright hope you feel better | D2N107 | 21 | [
"Chitchat"
] | [
"Null"
] | doctor: alright alright hope you feel better | 2,754 |
doctor: hey gregory good to see you today so take a look at my notes and i see that you're here you've had a nonhealing foot ulcer so can you tell me how you're doing how long have you had it what's going on with it patient: sure so i've had it for about two months now and it's recently become red and is draining so i ... | D2N108 | 0 | [
"Personal History",
"Greetings"
] | [
"Subjective"
] | hey gregory good to see you today so take a look at my notes and i see that you're here you've had a nonhealing foot ulcer so can you tell me how you're doing how long have you had it what's going on with it | 2,755 |
doctor: okay and when you when you got it would you have any trauma to your foot or it just just did it pop up all of a sudden patient: i think i may have gotten it from walking barefoot on the beach | D2N108 | 1 | [
"Personal History"
] | [
"Subjective"
] | okay and when you when you got it would you have any trauma to your foot or it just just did it pop up all of a sudden | 2,756 |
doctor: okay alright and i saw you you did see your pcp before you came in did they put you on antibiotics patient: they did start me on some medication but i did n't i did n't pick them up from the pharmacy yet | D2N108 | 2 | [
"Therapeutic History"
] | [
"Subjective"
] | okay alright and i saw you you did see your pcp before you came in did they put you on antibiotics | 2,757 |
doctor: okay do you know which ones that they prescribed for you patient: i do n't recall the name exactly | D2N108 | 3 | [
"Therapeutic History"
] | [
"Subjective"
] | okay do you know which ones that they prescribed for you | 2,758 |
doctor: do n't recall alright patient: something i had taken it before | D2N108 | 4 | [
"Therapeutic History"
] | [
"Subjective"
] | do n't recall alright | 2,759 |
doctor: okay so when you what beach did you go to when you you hurt it patient: i'm sorry | D2N108 | 5 | [
"Other Socials"
] | [
"Subjective"
] | okay so when you what beach did you go to when you you hurt it | 2,760 |
doctor: so i was asking which beach did you did you go to when you hurt your foot patient: at i was at dewey beach in my ambulance | D2N108 | 6 | [
"Other Socials"
] | [
"Subjective"
] | so i was asking which beach did you did you go to when you hurt your foot | 2,761 |
doctor: dewey beach wow that sounds like fun i wish i could be a mab right now but all or as lucky as i guess as you are to go to dewey beach okay so does it hurt patient: it sometimes it throbs does n't i do n't have specific pain but sometimes it does feel like there is some throbbing going on and again my my biggest... | D2N108 | 7 | [
"Acute Symptoms"
] | [
"Subjective"
] | dewey beach wow that sounds like fun i wish i could be a mab right now but all or as lucky as i guess as you are to go to dewey beach okay so does it hurt | 2,762 |
doctor: okay and that makes sense alright so as far as your diabetes you know and i think that's probably a a major cause of this not being able to heal how well are how well is that controlled patient: i take my medication but i do n't check my sugar all the time | D2N108 | 9 | [
"Personal History",
"Reassessment"
] | [
"Subjective",
"Assessment"
] | okay and that makes sense alright so as far as your diabetes you know and i think that's probably a a major cause of this not being able to heal how well are how well is that controlled | 2,763 |
doctor: okay do you patient: i'm not really sure how | D2N108 | 10 | [
"Chitchat"
] | [
"Null"
] | okay do you | 2,764 |
doctor: okay do you know what your last a1c is i'm pretty sure you doc talk to you about it patient: i think they told me it was around ten | D2N108 | 11 | [
"Personal History"
] | [
"Subjective"
] | okay do you know what your last a1c is i'm pretty sure you doc talk to you about it | 2,765 |
doctor: around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look nor... | D2N108 | 12 | [
"Physical Examination"
] | [
"Objective"
] | around ten okay yeah that that's that's definitely pretty high yeah you definitely if your if your pcp has n't gotten created treatment plan for you definitely need to go back and see them so you can get that controlled alright so let me do a quick physical exam on your foot here today your vital signs look normal you ... | 2,766 |
doctor: okay alright that's good so before you came in we did get an x-ray of your right foot and there is no evidence of osteomyelitis that means that luckily you do n't have a bone infection so that's great i think it's just in your skin so let's talk a little bit about your assessment and plan so you do have that di... | D2N108 | 13 | [
"Discussion",
"Medication",
"Other Treatments",
"Radiology Examination",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | okay alright that's good so before you came in we did get an x-ray of your right foot and there is no evidence of osteomyelitis that means that luckily you do n't have a bone infection so that's great i think it's just in your skin so let's talk a little bit about your assessment and plan so you do have that diabetic f... | 2,767 |
doctor: okay yeah we could definitely get you a a shoe because if you wear your regular shoes that pressure on that foot can really irritate it and take you backwards so i'll get you a shoe where you can wear that for the next month you know we just wan na make sure that it does heal and then i wan na see you back agai... | D2N108 | 14 | [
"Discussion",
"Follow-up",
"Other Treatments"
] | [
"Plan"
] | okay yeah we could definitely get you a a shoe because if you wear your regular shoes that pressure on that foot can really irritate it and take you backwards so i'll get you a shoe where you can wear that for the next month you know we just wan na make sure that it does heal and then i wan na see you back again in two... | 2,768 |
doctor: alright do you have any other question patient: i do if anything happens in between | D2N108 | 15 | [
"Discussion"
] | [
"Plan"
] | alright do you have any other question | 2,769 |
doctor: please feel free to call the office yeah please feel free to call you call the office we can definitely get you in you know if you are having any other issues and if it's an emergency if you feel like you're getting a fever feeling well please go to the urgent care or the er if you feel getting black or anythin... | D2N108 | 16 | [
"Follow-up"
] | [
"Plan"
] | please feel free to call the office yeah please feel free to call you call the office we can definitely get you in you know if you are having any other issues and if it's an emergency if you feel like you're getting a fever feeling well please go to the urgent care or the er if you feel getting black or anything like t... | 2,770 |
doctor: alright great | D2N108 | 17 | [
"Chitchat"
] | [
"Null"
] | doctor: alright great | 2,771 |
doctor: so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle patient: well we had a long spring and the other day we got some snow and ice i was walking to my car and i slippe... | D2N109 | 0 | [
"Acute Symptoms",
"Personal History",
"Greetings"
] | [
"Subjective"
] | so stephanie morales is a 36 -year-old female today complaining of her ankle pain and she also has a history of diabetes and high blood pressure so stephanie tell me what's going on with your ankle | 2,772 |
doctor: okay and so this happened couple days ago or how many days ago patient: two days ago | D2N109 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and so this happened couple days ago or how many days ago | 2,773 |
doctor: two days ago okay and so it's your left ankle and it kinda just twisted underneath you on the kind of on the inside patient: yeah more on the it's more on the outside of my hips | D2N109 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | two days ago okay and so it's your left ankle and it kinda just twisted underneath you on the kind of on the inside | 2,774 |
doctor: and did you fall down or did you just kind of cut catch yourself patient: no i fell | D2N109 | 3 | [
"Acute Symptoms"
] | [
"Subjective"
] | and did you fall down or did you just kind of cut catch yourself | 2,775 |
doctor: okay and were you able to get up afterwards or somebody helped you up patient: i was but it was very sore and then started swelling and quite a bit of pain so it's hard to walk | D2N109 | 4 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and were you able to get up afterwards or somebody helped you up | 2,776 |
doctor: sure have you tried anything for pain or the swelling or anything like that patient: ibuprofen some ice and elevation | D2N109 | 5 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | sure have you tried anything for pain or the swelling or anything like that | 2,777 |
doctor: okay has that helped much or not really patient: a little bit | D2N109 | 6 | [
"Acute Symptoms",
"Therapeutic History"
] | [
"Subjective"
] | okay has that helped much or not really | 2,778 |
doctor: okay and any pain above your ankle does it hurt on your on your calf or your lower leg at all or knee at all patient: no it's mostly just the outside of my ankle | D2N109 | 7 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and any pain above your ankle does it hurt on your on your calf or your lower leg at all or knee at all | 2,779 |
doctor: okay got it and no bleeding or i'm sure it's a little swollen probably patient: yeah it's swollen but no bleeding | D2N109 | 8 | [
"Vegetative History"
] | [
"Subjective"
] | okay got it and no bleeding or i'm sure it's a little swollen probably | 2,780 |
doctor: well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood s... | D2N109 | 9 | [
"Personal History"
] | [
"Subjective"
] | well i'll have you take off your shoes in a second we'll examine you in a second but since you're here and i wanted to talk about some of your other things that you know we have n't i have n't seen you in a year so let's talk about your history of diabetes as well are you taking the metformin how's your blood sugars be... | 2,781 |
doctor: you're checking your sugars regularly as well patient: yes | D2N109 | 12 | [
"Personal History"
] | [
"Subjective"
] | you're checking your sugars regularly as well | 2,782 |
doctor: okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you s... | D2N109 | 13 | [
"Discussion",
"Diagnostic Testing",
"Reassessment"
] | [
"Assessment",
"Plan"
] | okay your hemoglobin a1c last time i looked at epic was about six . eight which is really good so i think you're doing a great job we had talked about you know cutting off the sweets and sugars and stuff like that and exercising so it sounds like you're you're you're doing a pretty good job with that have you seen the ... | 2,783 |
doctor: okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that patient: i have an appointment | D2N109 | 14 | [
"Discussion",
"Diagnostic Testing"
] | [
"Plan"
] | okay alright so we'll so you do you already have an appointment or do you need to make an appointment for that | 2,784 |
doctor: perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything patient: i need a refill on that yes | D2N109 | 15 | [
"Discussion",
"Medication"
] | [
"Plan"
] | perfect excellent okay and how is your blood pressure been i know we watching it your blood pressure today looks pretty good it's about one seventy over i'm sorry one twenty over seventy you're taking norvasc any issues with that any do you need any refills or anything | 2,785 |
doctor: okay alright well let me examine you here for a second so i'm gon na go ahead and do my match exam and i'm just gon na verbalize some of my findings so i can put that into my record okay so your neck exam is fine there is no bruits your lungs are clear your heart exam is normal you do have a two over six systol... | D2N109 | 16 | [
"Physical Examination",
"Discussion",
"Other Treatments",
"Diagnostic Testing",
"Acute Assessment"
] | [
"Objective",
"Assessment",
"Plan"
] | okay alright well let me examine you here for a second so i'm gon na go ahead and do my match exam and i'm just gon na verbalize some of my findings so i can put that into my record okay so your neck exam is fine there is no bruits your lungs are clear your heart exam is normal you do have a two over six systolic eject... | 2,786 |
doctor: perfect and for the diabetes keep the eye appointment that you already have you know continue with the metformin i'm gon na order another hemoglobin a1c today we'll check some baseline labs as well since it's been a while since we checked them and then once if you have any issues or you know give me a call we c... | D2N109 | 18 | [
"Follow-up",
"Medication",
"Diagnostic Testing"
] | [
"Plan"
] | perfect and for the diabetes keep the eye appointment that you already have you know continue with the metformin i'm gon na order another hemoglobin a1c today we'll check some baseline labs as well since it's been a while since we checked them and then once if you have any issues or you know give me a call we can get y... | 2,787 |
doctor: sounds good sounds good good great seeing you thanks stephanie patient: thank you | D2N109 | 19 | [
"Chitchat"
] | [
"Null"
] | sounds good sounds good good great seeing you thanks stephanie | 2,788 |
doctor: okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right patient: yes | D2N110 | 0 | [
"Acute Symptoms",
"Greetings"
] | [
"Subjective"
] | okay hi wayne well i understand you're here for you've got a sore on your foot that's not healing is that right | 2,789 |
doctor: so can you tell me about that how are you doing patient: well i've been doing okay but i've had this wound on my right foot for a couple of weeks and it's not getting better i saw my pcp and they referred me to you i i used to see a podiatrist and a couple of years ago but they moved and i was n't able to get a... | D2N110 | 1 | [
"Acute Symptoms"
] | [
"Subjective"
] | so can you tell me about that how are you doing | 2,790 |
doctor: okay and how long have you had the wound patient: about two to three weeks | D2N110 | 2 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay and how long have you had the wound | 2,791 |
doctor: okay have you had any kind of trauma to that foot patient: no i bought a new pair of shoes to travel with and the neuropathy i guess i did n't feel that they were too tight at first it was just a blister but it looked a lot worse now i've been putting a band-aid on it and | D2N110 | 3 | [
"Personal History"
] | [
"Subjective"
] | okay have you had any kind of trauma to that foot | 2,792 |
doctor: okay and so did your doctor put you on any antibiotics when they they saw your foot patient: yes i finished the course yesterday the wound looked about the same though | D2N110 | 4 | [
"Personal History",
"Therapeutic History"
] | [
"Subjective"
] | okay and so did your doctor put you on any antibiotics when they they saw your foot | 2,793 |
doctor: okay now does it hurt patient: no i ca n't feel it | D2N110 | 5 | [
"Acute Symptoms"
] | [
"Subjective"
] | okay now does it hurt | 2,794 |
doctor: okay now have you had any other symptoms like fever chills drainage from the wound or anything along those lines patient: no but when i take my sock off sometimes it sticks to the wound even when i put a band-aid on | D2N110 | 6 | [
"Vegetative History"
] | [
"Subjective"
] | okay now have you had any other symptoms like fever chills drainage from the wound or anything along those lines | 2,795 |
doctor: okay well are you still wearing those same shoes that cause the problem patient: no i'm upset | D2N110 | 7 | [
"Other Socials"
] | [
"Subjective"
] | okay well are you still wearing those same shoes that cause the problem | 2,796 |
doctor: i'm so upset too i love those shoes patient: no i'm so upset i i love those shoes | D2N110 | 8 | [
"Chitchat"
] | [
"Null"
] | i'm so upset too i love those shoes | 2,797 |
doctor: okay so what kind of shoes are they patient: they're hoka's | D2N110 | 9 | [
"Other Socials"
] | [
"Subjective"
] | okay so what kind of shoes are they | 2,798 |
doctor: ah so where did you get them patient: i got them at rei couple of years ago | D2N110 | 10 | [
"Other Socials"
] | [
"Subjective"
] | ah so where did you get them | 2,799 |
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